1
|
Lowry MTH, Doudesis D, Boeddinghaus J, Kimenai DM, Bularga A, Taggart C, Wereski R, Ferry AV, Stewart SD, Tuck C, Koechlin L, Nestelberger T, Lopez-Ayala P, Huré G, Lee KK, Chapman AR, Newby DE, Anand A, Collinson PO, Mueller C, Mills NL. Troponin in early presenters to rule out myocardial infarction. Eur Heart J 2023; 44:2846-2858. [PMID: 37350492 PMCID: PMC10406338 DOI: 10.1093/eurheartj/ehad376] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/12/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023] Open
Abstract
AIMS Whether a single cardiac troponin measurement can safely rule out myocardial infarction in patients presenting within a few hours of symptom onset is uncertain. The study aim was to assess the performance of troponin in early presenters. METHODS AND RESULTS In patients with possible myocardial infarction, the diagnostic performance of a single measurement of high-sensitivity cardiac troponin I at presentation was evaluated and externally validated in those tested ≤3, 4-12, and >12 h from symptom onset. The limit-of-detection (2 ng/L), rule-out (5 ng/L), and sex-specific 99th centile (16 ng/L in women; 34 ng/L in men) thresholds were compared. In 41 103 consecutive patients [60 (17) years, 46% women], 12 595 (31%) presented within 3 h, and 3728 (9%) had myocardial infarction. In those presenting ≤3 h, a threshold of 2 ng/L had greater sensitivity and negative predictive value [99.4% (95% confidence interval 99.2%-99.5%) and 99.7% (99.6%-99.8%)] compared with 5 ng/L [96.5% (96.2%-96.8%) and 99.3% (99.1%-99.4%)]. In those presenting ≥3 h, the sensitivity and negative predictive value were similar for both thresholds. The sensitivity of the 99th centile was low in early and late presenters at 71.4% (70.6%-72.2%) and 92.5% (92.0%-93.0%), respectively. Findings were consistent in an external validation cohort of 7088 patients. CONCLUSION In early presenters, a single measurement of high-sensitivity cardiac troponin I below the limit of detection may facilitate the safe rule out of myocardial infarction. The 99th centile should not be used to rule out myocardial infarction at presentation even in those presenting later following symptom onset.
Collapse
Affiliation(s)
- Matthew T H Lowry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
- Usher Institute, 9 Little France Road, BioQuarter, Edinburgh, EH16 4UX, UK
| | - Jasper Boeddinghaus
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Dorien M Kimenai
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Stacey D Stewart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Christopher Tuck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Paul O Collinson
- Department of Clinical Blood Sciences, St George’s, University Hospitals NHS Trust and St George’s University of London, London, UK
- Department Cardiology, St George’s, University Hospitals NHS Trust and St George’s University of London, London, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
- Usher Institute, 9 Little France Road, BioQuarter, Edinburgh, EH16 4UX, UK
| |
Collapse
|
2
|
Jodeiri K, Foerster A, Trindade GF, Im J, Carballares D, Fernández-Lafuente R, Pita M, De Lacey AL, Parmenter CD, Tuck C. Additively Manufactured 3D Micro-bioelectrodes for Enhanced Bioelectrocatalytic Operation. ACS Appl Mater Interfaces 2023; 15:14914-14924. [PMID: 36897174 PMCID: PMC10037242 DOI: 10.1021/acsami.2c20262] [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] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/02/2023] [Indexed: 06/18/2023]
Abstract
The drive toward miniaturization of enzyme-based bioelectronics established a need for three-dimensional (3D) microstructured electrodes, which are difficult to implement using conventional manufacturing processes. Additive manufacturing coupled with electroless metal plating enables the production of 3D conductive microarchitectures with high surface area for potential applications in such devices. However, interfacial delamination between the metal layer and the polymer structure is a major reliability concern, which leads to device performance degradation and eventually device failure. This work demonstrates a method to produce a highly conductive and robust metal layer on a 3D printed polymer microstructure with strong adhesion by introducing an interfacial adhesion layer. Prior to 3D printing, multifunctional acrylate monomers with alkoxysilane (-Si-(OCH3)3) were synthesized via the thiol-Michael addition reaction between pentaerythritol tetraacrylate (PETA) and 3-mercaptopropyltrimethoxysilane (MPTMS) with a 1:1 stoichiometric ratio. Alkoxysilane functionality remains intact during photopolymerization in a projection micro-stereolithography (PμSLA) system and is utilized for the sol-gel reaction with MPTMS during postfunctionalization of the 3D printed microstructure to build an interfacial adhesion layer. This leads to the implementation of abundant thiol functional groups on the surface of the 3D printed microstructure, which can act as a strong binding site for gold during electroless plating to improve interfacial adhesion. The 3D conductive microelectrode prepared by this technique exhibited excellent conductivity of 2.2 × 107 S/m (53% of bulk gold) with strong adhesion between a gold layer and a polymer structure even after harsh sonication and an adhesion tape test. As a proof-of-concept, we examined the 3D gold diamond lattice microelectrode modified with glucose oxidase as a bioanode for a single enzymatic biofuel cell. The lattice-structured enzymatic electrode with high catalytic surface area was able to generate a current density of 2.5 μA/cm2 at 0.35 V, which is an about 10 times increase in current output compared to a cube-shaped microelectrode.
Collapse
Affiliation(s)
- Keyvan Jodeiri
- Centre
for Additive Manufacturing, Faculty of Engineering, University of
Nottingham, University Park, Nottingham NG7 2RD, United Kingdom
| | - Aleksandra Foerster
- Centre
for Additive Manufacturing, Faculty of Engineering, University of
Nottingham, University Park, Nottingham NG7 2RD, United Kingdom
| | - Gustavo F. Trindade
- Centre
for Additive Manufacturing, Faculty of Engineering, University of
Nottingham, University Park, Nottingham NG7 2RD, United Kingdom
- National
Physical Laboratory, Hampton Road, Teddington TW11 0LW, United Kingdom
| | - Jisun Im
- Centre
for Additive Manufacturing, Faculty of Engineering, University of
Nottingham, University Park, Nottingham NG7 2RD, United Kingdom
| | - Diego Carballares
- Instituto
de Catálisis y Petroleoquímica, CSIC, C/Marie Curie 2, 28049 Cantoblanco, Madrid, Spain
| | - Roberto Fernández-Lafuente
- Instituto
de Catálisis y Petroleoquímica, CSIC, C/Marie Curie 2, 28049 Cantoblanco, Madrid, Spain
- Center
of Excellence in Bionanoscience Research, Member of the External Scientific
Advisory Board, King Abdulaziz University, 21589 Jeddah, Saudi Arabia
| | - Marcos Pita
- Instituto
de Catálisis y Petroleoquímica, CSIC, C/Marie Curie 2, 28049 Cantoblanco, Madrid, Spain
| | - Antonio L. De Lacey
- Instituto
de Catálisis y Petroleoquímica, CSIC, C/Marie Curie 2, 28049 Cantoblanco, Madrid, Spain
| | - Christopher D Parmenter
- Nanoscale
and Microscale Research Centre, University of Nottingham, University Park, Nottingham NG7 2RD, United Kingdom
| | - Christopher Tuck
- Centre
for Additive Manufacturing, Faculty of Engineering, University of
Nottingham, University Park, Nottingham NG7 2RD, United Kingdom
| |
Collapse
|
3
|
Lowry MT, Doudesis D, Wereski R, Kimenai DM, Tuck C, Ferry AV, Bularga A, Taggart C, Lee KK, Chapman AR, Shah AS, Newby DE, Mills NL, Anand A. Influence of Age on the Diagnosis of Myocardial Infarction. Circulation 2022; 146:1135-1148. [PMID: 36106552 PMCID: PMC9555758 DOI: 10.1161/circulationaha.122.059994] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/04/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The 99th centile of cardiac troponin, derived from a healthy reference population, is recommended as the diagnostic threshold for myocardial infarction, but troponin concentrations are strongly influenced by age. Our aim was to assess the diagnostic performance of cardiac troponin in older patients presenting with suspected myocardial infarction. METHODS In a secondary analysis of a multicenter trial of consecutive patients with suspected myocardial infarction, we assessed the diagnostic accuracy of high-sensitivity cardiac troponin I at presentation for the diagnosis of type 1, type 2, or type 4b myocardial infarction across 3 age groups (<50, 50-74, and ≥75 years) using guideline-recommended sex-specific and age-adjusted 99th centile thresholds. RESULTS In 46 435 consecutive patients aged 18 to 108 years (mean, 61±17 years), 5216 (11%) had a diagnosis of myocardial infarction. In patients <50 (n=12 379), 50 to 74 (n=22 380), and ≥75 (n=11 676) years, the sensitivity of the guideline-recommended threshold was similar at 79.2% (95% CI, 75.5-82.9), 80.6% (95% CI, 79.2-82.1), and 81.6% (95% CI, 79.8-83.2), respectively. The specificity decreased with advancing age from 98.3% (95% CI, 98.1-98.5) to 95.5% (95% CI, 95.2-95.8), and 82.6% (95% CI, 81.9-83.4). The use of age-adjusted 99th centile thresholds improved the specificity (91.3% [90.8%-91.9%] versus 82.6% [95% CI, 81.9%-83.4%]) and positive predictive value (59.3% [57.0%-61.5%] versus 51.5% [49.9%-53.3%]) for myocardial infarction in patients ≥75 years but failed to prevent the decrease in either parameter with increasing age and resulted in a marked reduction in sensitivity compared with the use of the guideline-recommended threshold (55.9% [53.6%-57.9%] versus 81.6% [79.8%-83.3%]. CONCLUSIONS Age alters the diagnostic performance of cardiac troponin, with reduced specificity and positive predictive value in older patients when applying the guideline-recommended or age-adjusted 99th centiles. Individualized diagnostic approaches rather than the adjustment of binary thresholds are needed in an aging population.
Collapse
Affiliation(s)
- Matthew T.H. Lowry
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
- Usher Institute (D.D., N.L.M.), University of Edinburgh, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Dorien M. Kimenai
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Christopher Tuck
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Amy V. Ferry
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Kuan K. Lee
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Andrew R. Chapman
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Anoop S.V. Shah
- Department of Non-communicable Disease, London School of Hygiene and Tropical Medicine, UK (A.S.V.S.)
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK (A.S.V.S.)
| | - David E. Newby
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
- Usher Institute (D.D., N.L.M.), University of Edinburgh, UK
| |
Collapse
|
4
|
Lowry M, Doudesis D, Kimenai D, Bularga A, Taggart C, Wereski R, Ferry A, Stewart S, Tuck C, Lee K, Chapman A, Shah A, Newby D, Anand A, Mills N. Impact of time from symptom onset on the diagnostic performance of high-sensitivity cardiac troponin for type 1 myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1346] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
High-sensitivity cardiac troponin has enabled the rapid rule-out and rule-in of myocardial infarction at presentation. However, increases in cardiac troponin may not be detectable early after symptom onset, and uncertainty remains as to how time of symptom onset influences diagnostic performance.
Purpose
To evaluate the impact of time from symptom onset on the diagnostic performance of high-sensitivity cardiac troponin for type 1 myocardial infarction.
Methods
In a secondary analysis of a prospective multicentre randomised controlled trial of consecutive patients with suspected acute coronary syndrome, we evaluated the diagnostic performance of high-sensitivity cardiac troponin I measurements at presentation stratified by time of symptom onset to blood sampling. Diagnostic performance was evaluated in four groups (≤3 hours, 4–6 hours, 7–12 hours and >12 hours from symptom onset) for recommended thresholds to rule-out (sex-specific 99th centile and optimised threshold [64 ng/L]) type 1 myocardial infarction.
Results
This analysis included 41,104 patients (median 60 [interquartile range 49–74] years, 46% female) of which 12,595 (31%), 10,298 (25%), 7,171 (17%) and 11,040 (27%) presented ≤3 hours, 4–6 hours, 7–12 hours and >12 hours, respectively. Type 1 myocardial infarction was the adjudicated diagnosis in 3,692 (9%) patients. For the rule-out of type 1 myocardial infarction, sensitivity was highest in those tested 7–12 hours from symptom onset and lowest in those tested ≤3 hours. In early presenters, a threshold of <2 ng/L had greater sensitivity and negative predictive value (99.4% [95% CI 98.9 to 99.7%] and 99.7% [95% CI 99.5 to 99.9%]) compared to <5 ng/L (96.7% [95% CI 95.7 to 97.6%] and 99.3% [95% CI 99.1 to 99.5%], respectively). In those tested >3 hrs from symptom onset, the sensitivity and negative predictive value for both thresholds were similar, but a threshold of <5 ng/L correctly ruled out more patients (60% [17,056/28,506] versus 29% [8,316/28,506]). For the rule-in of myocardial infarction, the sensitivity of the 99th centile and 64 ng/L was lowest in patients tested within 3 hours (71.7% [95% CI 69.3 to 74.1%] and 46.5% [95% CI 44.1 to 49.2%], respectively), and increased in those tested later from symptom onset. The specificity and positive predictive value were highest when testing was performed 7–12 hours from symptom onset for the sex-specific 99th centile (92.4% [95% CI 91.8 to 93.0%] and 51.3% [95% CI 48.2–54.5%]) and 64 ng/L (96.2% [95% CI 95.7 to 96.7%] and 61.2% [95% CI 57.3 to 65.2%]).
Conclusions
The diagnostic performance of cardiac troponin for myocardial infarction is strongly influenced by the time from symptom onset to testing. In early presenters the limit of detection may facilitate immediate rule-out of myocardial infarction, but otherwise testing at least 3 hours from symptom onset is needed with the optimal time to rule-in myocardial infarction being 7–12 hours from the onset of symptoms.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation (BHF)Medical Research council UK (MRC)
Collapse
Affiliation(s)
- M Lowry
- University of Edinburgh , Edinburgh , United Kingdom
| | - D Doudesis
- University of Edinburgh , Edinburgh , United Kingdom
| | - D Kimenai
- University of Edinburgh , Edinburgh , United Kingdom
| | - A Bularga
- University of Edinburgh , Edinburgh , United Kingdom
| | - C Taggart
- University of Edinburgh , Edinburgh , United Kingdom
| | - R Wereski
- University of Edinburgh , Edinburgh , United Kingdom
| | - A Ferry
- University of Edinburgh , Edinburgh , United Kingdom
| | - S Stewart
- University of Edinburgh , Edinburgh , United Kingdom
| | - C Tuck
- University of Edinburgh , Edinburgh , United Kingdom
| | - K Lee
- University of Edinburgh , Edinburgh , United Kingdom
| | - A Chapman
- University of Edinburgh , Edinburgh , United Kingdom
| | - A Shah
- University of Edinburgh , Edinburgh , United Kingdom
| | - D Newby
- University of Edinburgh , Edinburgh , United Kingdom
| | - A Anand
- University of Edinburgh , Edinburgh , United Kingdom
| | - N Mills
- University of Edinburgh , Edinburgh , United Kingdom
| |
Collapse
|
5
|
Doudesis D, Lee KK, Bularga A, Ferry AV, Tuck C, Anand A, Boeddinghaus J, Mueller C, Greenslade JH, Pickering JW, Than MP, Cullen L, Mills NL. Machine learning to optimise use of cardiac troponin in the diagnosis of acute myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1349] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Guidelines recommend fixed cardiac troponin thresholds for the assessment of patients with suspected acute coronary syndrome, however, performance varies in important patient groups as concentrations are influenced by age, sex and comorbidities. This limitation can be addressed using machine learning algorithms.
Methods
Machine learning algorithms were developed that integrate cardiac troponin concentrations at presentation or on serial testing with age, sex and clinical features in 10,038 consecutive emergency patients with suspected acute coronary syndrome. The primary outcome was an adjudicated diagnosis of type 1, type 4b or type 4c myocardial infarction. The best performing algorithm was selected for the CoDE-ACS (Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome) decision-support tool, and performance was externally validated in 3,035 patients pooled from three prospective studies.
Findings
CoDE-ACS had excellent discrimination and calibration using cardiac troponin at presentation (area under curve [AUC] 0.959, 95% confidence interval 0.948–0.971, Brier score 0.040), in the pooled external validation cohort. At presentation, the rule-out score identified 62.1% (1,885/3,035) of all patients as low-probability of myocardial infarction with a 99.5% (99.1–99.7%) negative predictive value and 97.0% (96.3–97.6%) sensitivity. The rule-in score identified 8.3% (252/3,035) of patients as high-probability with an 83.7% (82.4–85.0%) positive predictive value and 98.5% (98.0–98.9%) specificity. Performance of the rule-out and rule-in scores was consistent across patient subgroups (Figure 1 and Figure 2). CoDE-ACS incorporating a second cardiac troponin measurement also had excellent discrimination and calibration (AUC 0.971 [0.962–0.980], Brier score 0.039) and refined the individualised probabilities in the 29.5% (898/3,035) of patients neither ruled-out or ruled-in at presentation to guide further investigation.
Conclusions
We developed and externally validated the CoDE-ACS decision-support tool using machine learning to aid in the diagnosis of myocardial infarction. CoDE-ACS had excellent diagnostic performance to rule-out and rule-in myocardial infarction at presentation, performed consistently across patient subgroups, and provided individualised probabilities to guide further care in those who require serial troponin measurements.
Conclusions
We developed and externally validated the CoDE-ACS decision-support tool using machine learning to aid in the diagnosis of myocardial infarction. CoDE-ACS had excellent diagnostic performance to rule-out and rule-in myocardial infarction at presentation, performed consistently across patient subgroups, and provided individualised probabilities to guide further care in those who require serial troponin measurements.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): National Institute for Health ResearchBritish Heart Foundation
Collapse
Affiliation(s)
- D Doudesis
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - K K Lee
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - A Bularga
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - A V Ferry
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - C Tuck
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - A Anand
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - J Boeddinghaus
- University of Basel, Cardiovascular Research Institute Basel and Department of Cardiology , Basel , Switzerland
| | - C Mueller
- University of Basel, Cardiovascular Research Institute Basel and Department of Cardiology , Basel , Switzerland
| | - J H Greenslade
- University of Queensland, School of Medicine , Brisbane , Australia
| | - J W Pickering
- University of Otago, Christchurch Heart Institute , Christchurch , New Zealand
| | - M P Than
- Christchurch Hospital , Christchurch , New Zealand
| | - L Cullen
- University of Queensland, School of Medicine , Brisbane , Australia
| | - N L Mills
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| |
Collapse
|
6
|
Lee K, Doudesis D, Ferry AV, Chapman AR, Kimenai D, Tuck C, Strachan FE, Newby DE, Anand A, Shah ASV, Mills NL. Implementation of high-sensitivity cardiac troponin and risk of myocardial infarction or death at 5 years: a stepped-wedge cluster-randomised controlled trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1351] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Implementation of a high-sensitivity cardiac troponin I assay with the sex-specific 99th centile as the diagnostic threshold identifies more patients with myocardial injury and infarction, but whether this impacts on long-term clinical outcomes is unknown.
Purpose
In a prespecified analysis of a stepped-wedge cluster-randomised controlled trial performed across ten hospitals in Scotland, we evaluated the impact of implementing a high-sensitivity cardiac troponin I assay on outcomes at 5 years in consecutive patients with suspected acute coronary syndrome.
Methods
Throughout the trial, all 48,282 patients had cardiac troponin I concentrations measured using both a contemporary (standard care) and high-sensitivity (implementation) assay. During standard care, results from the high-sensitivity assay were concealed and the contemporary assay was used to guide care. Hospitals were randomly allocated to early (n=5) or late (n=5) implementation of the high-sensitivity assay using the sex-specific 99th centile to guide care and results from the contemporary assay were concealed. Patients reclassified by the high-sensitivity assay were defined as those with cardiac troponin concentrations above the sex-specific 99th centile but below the contemporary assay diagnostic threshold. Subsequent myocardial infarction or all-cause death at 5 years was compared before and after implementation using an adjusted Cox proportional hazards model in those reclassified by the high-sensitivity assay and stratified by index diagnosis.
Results
Overall, 10,360 patients had cardiac troponin concentrations greater than the sex-specific 99th centile of whom 1,771 (17%) were reclassified by the high-sensitivity assay. Compared to those identified as having elevated cardiac troponin by the contemporary assay, patients reclassified by the high-sensitivity assay were more likely to have non-ischemic myocardial injury (54% versus 28%) and less likely to have type 1 myocardial infarction (33% versus 59%; P<0.001 for both). In those reclassified, the 5-year incidence of subsequent myocardial infarction or all-cause death was 63% (456/720) before and 54% (567/1051) after implementation of the high-sensitivity assay (adjusted hazard ratio [aHR] 0.75 [95% CI 0.57–0.98]) (Figure 1). Following implementation, subsequent myocardial infarction or all-cause death at 5 years was reduced in patients with non-ischemic myocardial injury (aHR 0.66 [0.51–0.86]) but not type 1 or type 2 myocardial infarction (aHR 0.90 [0.78–1.03] and 0.81 [0.55–1.20], respectively).
Conclusions
In patients with suspected acute coronary syndrome, implementation of a high-sensitivity cardiac troponin assay was associated with a lower risk of subsequent myocardial infarction or death at 5 years. Improvements in outcome were greater in those with a diagnosis of non-ischemic myocardial injury rather than infarction.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): British Heart Foundation
Collapse
Affiliation(s)
- K Lee
- University of Edinburgh , Edinburgh , United Kingdom
| | - D Doudesis
- University of Edinburgh , Edinburgh , United Kingdom
| | - A V Ferry
- University of Edinburgh , Edinburgh , United Kingdom
| | - A R Chapman
- University of Edinburgh , Edinburgh , United Kingdom
| | - D Kimenai
- University of Edinburgh , Edinburgh , United Kingdom
| | - C Tuck
- University of Edinburgh , Edinburgh , United Kingdom
| | - F E Strachan
- University of Edinburgh , Edinburgh , United Kingdom
| | - D E Newby
- University of Edinburgh , Edinburgh , United Kingdom
| | - A Anand
- University of Edinburgh , Edinburgh , United Kingdom
| | - A S V Shah
- London School of Hygiene and Tropical Medicine , London , United Kingdom
| | - N L Mills
- University of Edinburgh , Edinburgh , United Kingdom
| |
Collapse
|
7
|
Bularga A, Kimenai DM, Taggart C, Lowry M, Wereski R, McCance K, Lee KK, Anand A, Strachan FE, Tuck C, Shah ASV, Chapman AR, Newby DE, Jenks S, Mills NL. Impact of patient selection on performance of an early rule-out pathway for myocardial infarction: from research to the real world. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1344] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Early rule-out pathways for myocardial infarction using high-sensitivity cardiac troponin are widely recommended in the assessment of patients with suspected acute coronary syndrome. Although developed in selected patients participating in research studies, these pathways are applied more widely in clinical practice where the diagnostic performance and effectiveness of these pathways may differ.
Purpose
To evaluate the performance of an early rule-out pathway for myocardial infarction using high-sensitivity cardiac troponin in selected and consecutive unselected patients with suspected acute coronary syndrome.
Methods
Presentation and serial high-sensitivity cardiac troponin I concentrations were measured in two cohorts of patients with suspected acute coronary syndrome presenting to the Emergency Departments across three acute care hospitals in Scotland. In the unselected cohort, electronic health record data were collected on consecutive patients in whom the usual care clinician measured cardiac troponin for suspected acute coronary syndrome. In the selected cohort, patients with suspected acute coronary syndrome were approached between 8am and 8pm by research staff and written informed consent obtained. In both cohorts, the performance of the High-STEACS early rule-out pathway was evaluated for an adjudicated diagnosis of myocardial infarction (type 1, type 4b or type 4c) during the index hospital admission.
Results
The unselected and selected patient cohorts comprised of 1,242 (median age 60 [interquartile range 47–75] years, 46% women) and 1,695 (median age 61 [52–73] years, 40% women) patients respectively. Myocardial infarction was diagnosed in 6% (74/1,242) and 14% (232/1,695) of patients in the unselected and selected patient cohorts respectively. More patients had myocardial infarction ruled-out in the unselected (74% [828/1,112] versus 66% [1,102/1,678]; P<0.001), with similar negative predictive value (99.9% [95% CI 99.7%-100%] versus 99.7% [95% CI 99.4%-99.0%) and sensitivity (99.3% [95% CI 97.4%-100%] versus 98.9% [95% CI 97.6%-99.9%]; Figure 1). In the selected cohort, more patients had intermediate troponin concentrations requiring serial testing (36% versus 29%) or had myocardial infarction diagnosed (34% versus 26%; P<0.001 for both). In contrast, the positive predictive value for myocardial infarction was lower in unselected patients (26.1% [95% CI 21.2%-31.4%] versus 39.9% [95% CI 35.9%-44.0%]).
Conclusion
The prevalence of myocardial infarction is lower in patients with suspected acute coronary syndrome evaluated in routine practice compared to those selected to participate in a research study. Whilst more patients have myocardial infarction accurately ruled out, the positive-predictive value in those ruled in is lower resulting in more hospital admissions with elevated cardiac troponin due to other conditions.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart FoundationMedical Research Council
Collapse
Affiliation(s)
- A Bularga
- University of Edinburgh , Edinburgh , United Kingdom
| | - D M Kimenai
- University of Edinburgh , Edinburgh , United Kingdom
| | - C Taggart
- University of Edinburgh , Edinburgh , United Kingdom
| | - M Lowry
- University of Edinburgh , Edinburgh , United Kingdom
| | - R Wereski
- University of Edinburgh , Edinburgh , United Kingdom
| | - K McCance
- University of Edinburgh, Department Clinical Biochemistry, , Edinburgh , United Kingdom
| | - K K Lee
- University of Edinburgh , Edinburgh , United Kingdom
| | - A Anand
- University of Edinburgh , Edinburgh , United Kingdom
| | - F E Strachan
- University of Edinburgh , Edinburgh , United Kingdom
| | - C Tuck
- University of Edinburgh , Edinburgh , United Kingdom
| | - A S V Shah
- London School of Hygiene and Tropical Medicine, Department of Cardiology , London , United Kingdom
| | - A R Chapman
- University of Edinburgh , Edinburgh , United Kingdom
| | - D E Newby
- University of Edinburgh , Edinburgh , United Kingdom
| | - S Jenks
- Royal Infirmary of Edinburgh, Department of Clinical Biochemistry , Edinburgh , United Kingdom
| | - N L Mills
- University of Edinburgh , Edinburgh , United Kingdom
| |
Collapse
|
8
|
Rodriguez A, Tuck C, Dozier MF, Lewis SC, Eldridge S, Jackson T, Murray A, Weir CJ. Current recommendations/practices for anonymising data from clinical trials in order to make it available for sharing: A scoping review. Clin Trials 2022; 19:452-463. [PMID: 35730910 PMCID: PMC9373195 DOI: 10.1177/17407745221087469] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background/Aims There are increasing pressures for anonymised datasets from clinical trials
to be shared across the scientific community, and differing recommendations
exist on how to perform anonymisation prior to sharing. We aimed to
systematically identify, describe and synthesise existing recommendations
for anonymising clinical trial datasets to prepare for data sharing. Methods We systematically searched MEDLINE®, EMBASE and Web of Science
from inception to 8 February 2021. We also searched other resources to
ensure the comprehensiveness of our search. Any publication reporting
recommendations on anonymisation to enable data sharing from clinical trials
was included. Two reviewers independently screened titles, abstracts and
full text for eligibility. One reviewer extracted data from included papers
using thematic synthesis, which then was sense-checked by a second reviewer.
Results were summarised by narrative analysis. Results Fifty-nine articles (from 43 studies) were eligible for inclusion. Three
distinct themes are emerging: anonymisation, de-identification and
pseudonymisation. The most commonly used anonymisation techniques are:
removal of direct patient identifiers; and careful evaluation and
modification of indirect identifiers to minimise the risk of identification.
Anonymised datasets joined with controlled access was the preferred method
for data sharing. Conclusions There is no single standardised set of recommendations on how to anonymise
clinical trial datasets for sharing. However, this systematic review shows a
developing consensus on techniques used to achieve anonymisation.
Researchers in clinical trials still consider that anonymisation techniques
by themselves are insufficient to protect patient privacy, and they need to
be paired with controlled access.
Collapse
Affiliation(s)
- Aryelly Rodriguez
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Christopher Tuck
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Marshall F Dozier
- Library & University Collections, Information Services, The University of Edinburgh, Edinburgh, UK
| | - Stephanie C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Tracy Jackson
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | | | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| |
Collapse
|
9
|
Im J, Trindade GF, Quach TT, Sohaib A, Wang F, Austin J, Turyanska L, Roberts CJ, Wildman R, Hague R, Tuck C. Functionalized Gold Nanoparticles with a Cohesion Enhancer for Robust Flexible Electrodes. ACS Appl Nano Mater 2022; 5:6708-6716. [PMID: 35655930 PMCID: PMC9150063 DOI: 10.1021/acsanm.2c00742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
The development of conductive inks is required to enable additive manufacturing of electronic components and devices. A gold nanoparticle (AuNP) ink is of particular interest due to its high electrical conductivity, chemical stability, and biocompatibility. However, a printed AuNP film suffers from thermally induced microcracks and pores that lead to the poor integrity of a printed electronic component and electrical failure under external mechanical deformation, hence limiting its application for flexible electronics. Here, we employ a multifunctional thiol as a cohesion enhancer in the AuNP ink to prevent the formation of microcracks and pores by mediating the cohesion of AuNPs via strong interaction between the thiol groups and the gold surface. The inkjet-printed AuNP electrode exhibits an electrical conductivity of 3.0 × 106 S/m and stable electrical properties under repeated cycles (>1000) of mechanical deformation even for a single printed layer and in a salt-rich phosphate-buffered saline solution, offering exciting potential for applications in flexible and 3D electronics as well as in bioelectronics and healthcare devices.
Collapse
Affiliation(s)
- Jisun Im
- Centre
for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, U.K.
| | - Gustavo F. Trindade
- Centre
for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, U.K.
- Advanced
Materials and Healthcare Technologies, School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, U.K.
| | - Tien Thuy Quach
- Centre
for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, U.K.
- Advanced
Materials and Healthcare Technologies, School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, U.K.
| | - Ali Sohaib
- Centre
for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, U.K.
| | - Feiran Wang
- Centre
for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, U.K.
| | - Jonathan Austin
- Centre
for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, U.K.
| | - Lyudmila Turyanska
- Centre
for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, U.K.
| | - Clive J. Roberts
- Advanced
Materials and Healthcare Technologies, School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, U.K.
| | - Ricky Wildman
- Centre
for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, U.K.
| | - Richard Hague
- Centre
for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, U.K.
| | - Christopher Tuck
- Centre
for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, U.K.
| |
Collapse
|
10
|
Ruiz-Cantu L, Trindade GF, Taresco V, Zhou Z, He Y, Burroughs L, Clark EA, Rose FRAJ, Tuck C, Hague R, Roberts CJ, Alexander M, Irvine DJ, Wildman RD. Correction to "Bespoke 3D-Printed Polydrug Implants Created via Microstructural Control of Oligomers". ACS Appl Mater Interfaces 2022; 14:8654. [PMID: 35107247 DOI: 10.1021/acsami.2c00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
|
11
|
Larder RR, Krumins E, Jacob PL, Kortsen K, Cavanagh R, Jiang L, Vuotto C, Francolini I, Tuck C, Taresco V, Howdle SM. Antimicrobial ‘inks’ for 3D printing: block copolymer-silver nanoparticle composites synthesised using supercritical CO 2. Polym Chem 2022. [DOI: 10.1039/d2py00398h] [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: 11/21/2022]
Abstract
A new synthetic methodology to produce polymer-AgNP composite microparticles using scCO2 is presented. These microparticle possessed long-lived antimicrobial activity and were tested for compatibility in the Laser Sintering 3D printing process.
Collapse
Affiliation(s)
- Ryan R. Larder
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Eduards Krumins
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, UK
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Philippa L. Jacob
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kristoffer Kortsen
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Robert Cavanagh
- School of Pharmacy, The University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Long Jiang
- School of Pharmacy, The University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Claudia Vuotto
- Microbial Biofilm Laboratory, IRCCS Fondazione Santa Lucia, 00143 Rome, Italy
| | | | - Christopher Tuck
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Vincenzo Taresco
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Steven M. Howdle
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| |
Collapse
|
12
|
|
13
|
Ruiz-Cantu L, F Trindade G, Taresco V, Zhou Z, He Y, Burroughs L, Clark EA, Rose FRAJ, Tuck C, Hague R, Roberts CJ, Alexander M, Irvine DJ, Wildman RD. Bespoke 3D-Printed Polydrug Implants Created via Microstructural Control of Oligomers. ACS Appl Mater Interfaces 2021; 13:38969-38978. [PMID: 34399054 DOI: 10.1021/acsami.1c07850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Controlling the microstructure of materials by means of phase separation is a versatile tool for optimizing material properties. Phase separation has been exploited to fabricate intricate microstructures in many fields including cell biology, tissue engineering, optics, and electronics. The aim of this study was to use phase separation to tailor the spatial location of drugs and thereby generate release profiles of drug payload over periods ranging from 1 week to months by exploiting different mechanisms: polymer degradation, polymer diluent dissolution, and control of microstructure. To achieve this, we used drop-on-demand inkjet three-dimensional (3D) printing. We predicted the microstructure resulting from phase separation using high-throughput screening combined with a model based on the Flory-Huggins interaction parameter and were able to show that drug release from 3D-printed objects can be predicted from observations based on single drops of mixtures. We demonstrated for the first time that inkjet 3D printing yields controllable phase separation using picoliter droplets of blended photoreactive oligomers/monomers. This new understanding gives us hierarchical compositional control, from droplet to device, allowing release to be "dialled up" without manipulation of device geometry. We exemplify this approach by fabricating a biodegradable, long-term, multiactive drug delivery subdermal implant ("polyimplant") for combination therapy and personalized treatment of coronary heart disease. This is an important advance for implants that need to be delivered by cannula, where the shape is highly constrained and thus the usual geometrical freedoms associated with 3D printing cannot be easily exploited, which brings a hitherto unseen level of understanding to emergent material properties of 3D printing.
Collapse
Affiliation(s)
- Laura Ruiz-Cantu
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, U.K
| | | | - Vincenzo Taresco
- School of Chemistry, University of Nottingham, Nottingham NG7 2RD, U.K
| | - Zuoxin Zhou
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, U.K
| | - Yinfeng He
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, U.K
| | | | - Elizabeth A Clark
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, U.K
| | | | - Christopher Tuck
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, U.K
| | - Richard Hague
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, U.K
| | - Clive J Roberts
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, U.K
| | - Morgan Alexander
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, U.K
| | - Derek J Irvine
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, U.K
| | - Ricky D Wildman
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, U.K
| |
Collapse
|
14
|
Aboulkhair NT, Simonelli M, Parry L, Ashcroft I, Tuck C, Hague R. 3D printing of Aluminium alloys: Additive Manufacturing of Aluminium alloys using selective laser melting. Progress in Materials Science 2019; 106:100578. [PMID: 0 DOI: 10.1016/j.pmatsci.2019.100578] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
|
15
|
Lee KK, Ferry AV, Anand A, Strachan FE, Chapman AR, Newby DB, Tuck C, Keerie C, Weir CJ, Shah ASV, Mills NL. P1731High-sensitivity troponin with sex-specific thresholds in suspected acute coronary syndrome. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0486] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Introduction
Major disparities between women and men in the diagnosis, management and outcome of acute coronary syndrome are well recognised. Whether sex-specific diagnostic thresholds for myocardial infarction will address these differences is uncertain.
Purpose
To evaluate the impact of implementing a high-sensitivity cardiac troponin I (hs-cTnI) assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome.
Methods
In a stepped-wedge, cluster-randomized controlled trial across ten hospitals we evaluated the implementation of a hs-cTnI assay in 48,282 (47% women) consecutive patients with suspected acute coronary syndrome. During a validation phase the hs-cTnI assay results were suppressed and a contemporary cTnI assay with a single threshold was used to guide care. Myocardial injury was defined as any hs-cTnI concentration >99th centile of 16 ng/L in women and 34 ng/L in men. The primary outcome was myocardial infarction after the initial presentation or cardiovascular death at 1 year. In this prespecified analysis, we evaluated outcomes in men and women before and after implementation of the hs-cTnI assay.
Results
Use of the hs-cTnI assay with sex-specific thresholds increased myocardial injury in women by 42% (from 3,521 (16%) to 4,991 (22%)) and by 6% in men (from 5,068 (20%) to 5,369 (21%)). Whilst treatment increased in both sexes, women with myocardial injury remained less likely than men to undergo coronary revascularisation (15% versus34%), or to receive dual anti-platelet (26% versus43%), statin (16% versus26%) or other preventative therapies (P<0.001 for all). The primary outcome occurred in 18% (369/2,072) and 17% (488/2,919) of women with myocardial injury during the validation and implementation phase respectively (adjusted hazard ratio 1.11, 95% confidence interval 0.92 to 1.33), compared to 18% (370/2,044) and 15% (513/3,325) of men (adjusted hazard ratio 0.85, 95% confidence interval 0.71 to 1.01).
Patient management
Conclusion
Use of sex-specific thresholds identified five-times more additional women than men with myocardial injury, such that the proportion of women and men with myocardial injury is now similar. Despite this increase, women received approximately half the number of treatments for coronary artery disease as men and their outcomes were not improved.
Acknowledgement/Funding
The British Heart Foundation
Collapse
Affiliation(s)
- K K Lee
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A V Ferry
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A Anand
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - F E Strachan
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A R Chapman
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - D B Newby
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - C Tuck
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - C Keerie
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - C J Weir
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A S V Shah
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - N L Mills
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| |
Collapse
|
16
|
Chapman AR, Adamson PD, Anand A, Shah ASV, Lee KK, Strachan FE, Ferry ASV, Sandeman DE, Berry C, Gray AJ, Tuck C, Fox KAA, Newby DE, Weir C, Mills NL. 249High-sensitivity cardiac troponin and the universal definition of myocardial infarction: a randomised controlled trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0066] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The Universal Definition of Myocardial Infarction recommends the 99th centile diagnostic threshold using a high-sensitivity cardiac troponin (hs-cTn) assay and the classification of patients by the etiology of myocardial injury. Whether implementation of this definition improves risk stratification, treatment or outcomes is unknown.
Methods
In a stepped-wedge cluster randomized controlled trial, we implemented a high-sensitivity troponin assay and the recommendations of the Universal Definition in 48,282 consecutive patients with suspected acute coronary syndrome across ten hospitals. In a pre-specified secondary analysis, we compared the primary outcome of myocardial infarction or cardiovascular death, and secondary outcome of non-cardiovascular death at one year across diagnostic categories as per the Fourth Universal Definition. We applied competing risks methodology in all analyses, using a cumulative incidence function and determining the cause-specific hazard ratio (csHR) for competing outcomes.
Results
Cardiac troponin concentrations were elevated in 21.5% (10,360/48,282) of all trial participants. Implementation increased the diagnosis of type 1 myocardial infarction by 11% (510/4,471), type 2 myocardial infarction by 22% (205/916), acute myocardial injury by 36% (443/1,233) and chronic myocardial injury by 43% (389/898). The risk and rate of the primary outcome was highest in those with type 1 myocardial infarction, whereas the risk and rate of non-cardiovascular death was highest in those with acute myocardial injury (Table, Figure). Despite increases in anti-platelet therapy and coronary revascularization after implementation, the primary outcome was unchanged in patients with type 1 myocardial infarction (csHR 1.00, 95% CI 0.82 to 1.21), or in any other category.
Adjusted csHR for competing outcomes Myocardial infarction or cardiovascular death Non-cardiovascular death Adjusted csHR (95% CI) Adjusted csHR (95% CI) Type 1 myocardial infarction 5.64 (5.12 to 6.22) 0.83 (0.72 to 0.96) Type 2 myocardial infarction 3.50 (2.94 to 4.15) 1.72 (1.44 to 2.06) Acute myocardial injury 4.38 (3.80 to 5.05) 2.65 (2.33 to 3.00) Chronic myocardial injury 3.88 (3.31 to 4.55) 2.06 (1.77 to 2.40) Cox regression models adjusted for age, sex, diabetes, ischaemic heart disease, season, days since trial onset and site of recruitment (as a random effect).
Cumulative incidence and number at risk
Conclusions
Implementation of the recommendations of the Universal Definition identified patients with different risks of future cardiovascular and non-cardiovascular events, but did not improve outcomes. Greater understanding of the underlying mechanisms and effective strategies for the investigation and treatment of patients with myocardial injury and infarction are required if we are to improve outcomes.
Acknowledgement/Funding
British Heart Foundation
Collapse
Affiliation(s)
- A R Chapman
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - P D Adamson
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A Anand
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A S V Shah
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - K K Lee
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - F E Strachan
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A S V Ferry
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - D E Sandeman
- Victoria Hospital, Cardiology, Kirkcaldy, United Kingdom
| | - C Berry
- Cardiovascular Research Centre of Glasgow, Glasgow, United Kingdom
| | - A J Gray
- Royal Infirmary of Edinburgh, Department of Emergency Medicine, Edinburgh, United Kingdom
| | - C Tuck
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - K A A Fox
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - D E Newby
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - C Weir
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - N L Mills
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| |
Collapse
|
17
|
Everett RJ, Tastet L, Clavel MA, Chin CWL, Capoulade R, Vassiliou VS, Kwiecinski J, Gomez M, van Beek EJR, White AC, Prasad SK, Larose E, Tuck C, Semple S, Newby DE, Pibarot P, Dweck MR. Progression of Hypertrophy and Myocardial Fibrosis in Aortic Stenosis: A Multicenter Cardiac Magnetic Resonance Study. Circ Cardiovasc Imaging 2019; 11:e007451. [PMID: 29914867 PMCID: PMC6023592 DOI: 10.1161/circimaging.117.007451] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 04/23/2018] [Indexed: 01/20/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Aortic stenosis is accompanied by progressive left ventricular hypertrophy and fibrosis. We investigated the natural history of these processes in asymptomatic patients and their potential reversal post-aortic valve replacement (AVR). Methods: Asymptomatic and symptomatic patients with aortic stenosis underwent repeat echocardiography and magnetic resonance imaging. Changes in peak aortic-jet velocity, left ventricular mass index, diffuse fibrosis (indexed extracellular volume), and replacement fibrosis (late gadolinium enhancement [LGE]) were quantified. Results: In 61 asymptomatic patients (43% mild, 34% moderate, and 23% severe aortic stenosis), significant increases in peak aortic-jet velocity, left ventricular mass index, indexed extracellular volume, and LGE mass were observed after 2.1±0.7 years, with the most rapid progression observed in patients with most severe stenosis. Patients with baseline midwall LGE (n=16 [26%]; LGE mass, 2.5 g [0.8–4.8 g]) demonstrated particularly rapid increases in scar burden (78% [50%–158%] increase in LGE mass per year). In 38 symptomatic patients (age, 66±8 years; 76% men) who underwent AVR, there was a 19% (11%–25%) reduction in left ventricular mass index (P<0.0001) and an 11% (4%–16%) reduction in indexed extracellular volume (P=0.003) 0.9±0.3 years after surgery. By contrast midwall LGE (n=10 [26%]; mass, 3.3 g [2.6–8.0 g]) did not change post-AVR (n=10; 3.5 g [2.1–8.0 g]; P=0.23), with no evidence of regression even out to 2 years. Conclusions: In patients with aortic stenosis, cellular hypertrophy and diffuse fibrosis progress in a rapid and balanced manner but are reversible after AVR. Once established, midwall LGE also accumulates rapidly but is irreversible post valve replacement. Given its adverse long-term prognosis, prompt AVR when midwall LGE is first identified may improve clinical outcomes. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01755936 and NCT01679431.
Collapse
Affiliation(s)
- Russell J Everett
- British Heart Foundation Centre for Cardiovascular Science (R.J.E., J.K., M.G., E.J.R.v.B., C.W., S.S., D.E.N., M.R.D.)
| | - Lionel Tastet
- University of Edinburgh, United Kingdom. Department of Medicine, Quebec Heart and Lung Institute, Canada (L.T., M.-A.C., R.C., E.L., P.P.)
| | - Marie-Annick Clavel
- University of Edinburgh, United Kingdom. Department of Medicine, Quebec Heart and Lung Institute, Canada (L.T., M.-A.C., R.C., E.L., P.P.)
| | - Calvin W L Chin
- Department of Cardiovascular Science, National Heart Center Singapore (C.W.L.C.)
| | - Romain Capoulade
- University of Edinburgh, United Kingdom. Department of Medicine, Quebec Heart and Lung Institute, Canada (L.T., M.-A.C., R.C., E.L., P.P.)
| | - Vassilios S Vassiliou
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom (V.S.V., S.K.P.).,Norwich Medical School, Norfolk and Norwich University Hospital, United Kingdom (V.S.V.)
| | - Jacek Kwiecinski
- British Heart Foundation Centre for Cardiovascular Science (R.J.E., J.K., M.G., E.J.R.v.B., C.W., S.S., D.E.N., M.R.D.).,First Department of Cardiology, Poznan University of Medical Sciences, Poland (J.K.)
| | - Miquel Gomez
- British Heart Foundation Centre for Cardiovascular Science (R.J.E., J.K., M.G., E.J.R.v.B., C.W., S.S., D.E.N., M.R.D.).,Hospital del Mar Medical Research Institute, Universitat Pompeu Fabra, Barcelona, Spain (M.G.)
| | - Edwin J R van Beek
- British Heart Foundation Centre for Cardiovascular Science (R.J.E., J.K., M.G., E.J.R.v.B., C.W., S.S., D.E.N., M.R.D.).,Edinburgh Imaging Queen's Medical Research Institute Facility (E.J.R.v.B., S.S.)
| | | | - Sanjay K Prasad
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom (V.S.V., S.K.P.)
| | - Eric Larose
- University of Edinburgh, United Kingdom. Department of Medicine, Quebec Heart and Lung Institute, Canada (L.T., M.-A.C., R.C., E.L., P.P.)
| | - Christopher Tuck
- British Heart Foundation Centre for Cardiovascular Science (R.J.E., J.K., M.G., E.J.R.v.B., C.W., S.S., D.E.N., M.R.D.).,Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics (C.T.)
| | - Scott Semple
- British Heart Foundation Centre for Cardiovascular Science (R.J.E., J.K., M.G., E.J.R.v.B., C.W., S.S., D.E.N., M.R.D.).,Edinburgh Imaging Queen's Medical Research Institute Facility (E.J.R.v.B., S.S.)
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science (R.J.E., J.K., M.G., E.J.R.v.B., C.W., S.S., D.E.N., M.R.D.)
| | - Philippe Pibarot
- University of Edinburgh, United Kingdom. Department of Medicine, Quebec Heart and Lung Institute, Canada (L.T., M.-A.C., R.C., E.L., P.P.)
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science (R.J.E., J.K., M.G., E.J.R.v.B., C.W., S.S., D.E.N., M.R.D.)
| |
Collapse
|
18
|
Giuri A, Saleh E, Listorti A, Colella S, Rizzo A, Tuck C, Esposito Corcione C. Rheological Tunability of Perovskite Precursor Solutions: From Spin Coating to Inkjet Printing Process. Nanomaterials (Basel) 2019; 9:nano9040582. [PMID: 30970624 PMCID: PMC6523128 DOI: 10.3390/nano9040582] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 12/01/2022]
Abstract
The high efficiencies (>22%) reached by perovskite-based optoelectronic devices in a very short period, demonstrates the great potential and tunability of this material. The current challenge lies in translating such efficiencies to commercially feasible forms produced through industrial fabrication methods. Herein, a novel first step towards the processability of starch-perovskite inks, developed in our previous work, is investigated, by using inkjet printing technology. The tunability of the viscosity of the starch-perovskite-based inks allows the selection of suitable concentrations to be used as printable inks. After exploration of several printing parameters, thick and opaque starch-perovskite nanocomposite films were obtained, showing interesting morphological and optical properties. The results obtained in this work underline the potential and versatility of our approach, opening the possibility to explore and optimize, in the future, further large-scale deposition methods towards fully printed and stable perovskite devices.
Collapse
Affiliation(s)
- Antonella Giuri
- Dipartimento di Ingegneria dell'Innovazione, Università del Salento, via per Monteroni, km 1, 73100 Lecce, Italy.
- Istituto di Nanotecnologia CNR-Nanotec, Polo di Nanotecnologia, c/o Campus Ecotekne, via Monteroni, 73100 Lecce, Italy.
| | - Ehab Saleh
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham NG8 1BB, UK.
- Future Manufacturing Processes Research Group, School of Mechanical Engineering, University of Leeds, Leeds LS2 9JT, UK.
| | - Andrea Listorti
- Istituto di Nanotecnologia CNR-Nanotec, Polo di Nanotecnologia, c/o Campus Ecotekne, via Monteroni, 73100 Lecce, Italy.
- Dipartimento di Matematica e Fisica "E. De Giorgi", Università del Salento, Via Arnesano snc, 73100 Lecce, Italy.
| | - Silvia Colella
- Istituto di Nanotecnologia CNR-Nanotec, Polo di Nanotecnologia, c/o Campus Ecotekne, via Monteroni, 73100 Lecce, Italy.
- Dipartimento di Matematica e Fisica "E. De Giorgi", Università del Salento, Via Arnesano snc, 73100 Lecce, Italy.
| | - Aurora Rizzo
- Istituto di Nanotecnologia CNR-Nanotec, Polo di Nanotecnologia, c/o Campus Ecotekne, via Monteroni, 73100 Lecce, Italy.
| | - Christopher Tuck
- Centre for Additive Manufacturing, Faculty of Engineering, University of Nottingham, Nottingham NG8 1BB, UK.
| | - Carola Esposito Corcione
- Dipartimento di Ingegneria dell'Innovazione, Università del Salento, via per Monteroni, km 1, 73100 Lecce, Italy.
- Istituto di Nanotecnologia CNR-Nanotec, Polo di Nanotecnologia, c/o Campus Ecotekne, via Monteroni, 73100 Lecce, Italy.
| |
Collapse
|
19
|
Shah ASV, Anand A, Strachan FE, Ferry AV, Lee KK, Chapman AR, Sandeman D, Stables CL, Adamson PD, Andrews JPM, Anwar MS, Hung J, Moss AJ, O'Brien R, Berry C, Findlay I, Walker S, Cruickshank A, Reid A, Gray A, Collinson PO, Apple FS, McAllister DA, Maguire D, Fox KAA, Newby DE, Tuck C, Harkess R, Parker RA, Keerie C, Weir CJ, Mills NL. High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial. Lancet 2018; 392:919-928. [PMID: 30170853 PMCID: PMC6137538 DOI: 10.1016/s0140-6736(18)31923-8] [Citation(s) in RCA: 214] [Impact Index Per Article: 35.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin assays permit use of lower thresholds for the diagnosis of myocardial infarction, but whether this improves clinical outcomes is unknown. We aimed to determine whether the introduction of a high-sensitivity cardiac troponin I (hs-cTnI) assay with a sex-specific 99th centile diagnostic threshold would reduce subsequent myocardial infarction or cardiovascular death in patients with suspected acute coronary syndrome. METHODS In this stepped-wedge, cluster-randomised controlled trial across ten secondary or tertiary care hospitals in Scotland, we evaluated the implementation of an hs-cTnI assay in consecutive patients who had been admitted to the hospitals' emergency departments with suspected acute coronary syndrome. Patients were eligible for inclusion if they presented with suspected acute coronary syndrome and had paired cardiac troponin measurements from the standard care and trial assays. During a validation phase of 6-12 months, results from the hs-cTnI assay were concealed from the attending clinician, and a contemporary cardiac troponin I (cTnI) assay was used to guide care. Hospitals were randomly allocated to early (n=5 hospitals) or late (n=5 hospitals) implementation, in which the high-sensitivity assay and sex-specific 99th centile diagnostic threshold was introduced immediately after the 6-month validation phase or was deferred for a further 6 months. Patients reclassified by the high-sensitivity assay were defined as those with an increased hs-cTnI concentration in whom cTnI concentrations were below the diagnostic threshold on the contemporary assay. The primary outcome was subsequent myocardial infarction or death from cardiovascular causes at 1 year after initial presentation. Outcomes were compared in patients reclassified by the high-sensitivity assay before and after its implementation by use of an adjusted generalised linear mixed model. This trial is registered with ClinicalTrials.gov, number NCT01852123. FINDINGS Between June 10, 2013, and March 3, 2016, we enrolled 48 282 consecutive patients (61 [SD 17] years, 47% women) of whom 10 360 (21%) patients had cTnI concentrations greater than those of the 99th centile of the normal range of values, who were identified by the contemporary assay or the high-sensitivity assay. The high-sensitivity assay reclassified 1771 (17%) of 10 360 patients with myocardial injury or infarction who were not identified by the contemporary assay. In those reclassified, subsequent myocardial infarction or cardiovascular death within 1 year occurred in 105 (15%) of 720 patients in the validation phase and 131 (12%) of 1051 patients in the implementation phase (adjusted odds ratio for implementation vs validation phase 1·10, 95% CI 0·75 to 1·61; p=0·620). INTERPRETATION Use of a high-sensitivity assay prompted reclassification of 1771 (17%) of 10 360 patients with myocardial injury or infarction, but was not associated with a lower subsequent incidence of myocardial infarction or cardiovascular death at 1 year. Our findings question whether the diagnostic threshold for myocardial infarction should be based on the 99th centile derived from a normal reference population. FUNDING The British Heart Foundation.
Collapse
Affiliation(s)
- Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Fiona E Strachan
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amy V Ferry
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Catherine L Stables
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Philip D Adamson
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jack P M Andrews
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Mohamed S Anwar
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - John Hung
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Alistair J Moss
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Rachel O'Brien
- Emergency Medicine Research Group of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Iain Findlay
- Department of Cardiology, Royal Alexandra Hospital, Paisley, UK
| | - Simon Walker
- Department of Clinical Biochemistry, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Anne Cruickshank
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alan Reid
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alasdair Gray
- Emergency Medicine Research Group of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Paul O Collinson
- Department of Clinical Blood Sciences and Department of Cardiology, St George's University Hospitals NHS Trust and St George's University of London, London, UK
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | | | - Donogh Maguire
- Emergency Medicine Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Keith A A Fox
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Christopher Tuck
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Ronald Harkess
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Richard A Parker
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
| |
Collapse
|
20
|
Saint R, Evans W, Zhou Y, Barrett T, Fromhold TM, Saleh E, Maskery I, Tuck C, Wildman R, Oručević F, Krüger P. 3D-printed components for quantum devices. Sci Rep 2018; 8:8368. [PMID: 29849028 PMCID: PMC5976634 DOI: 10.1038/s41598-018-26455-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 08/29/2017] [Accepted: 05/09/2018] [Indexed: 11/18/2022] Open
Abstract
Recent advances in the preparation, control and measurement of atomic gases have led to new insights into the quantum world and unprecedented metrological sensitivities, e.g. in measuring gravitational forces and magnetic fields. The full potential of applying such capabilities to areas as diverse as biomedical imaging, non-invasive underground mapping, and GPS-free navigation can only be realised with the scalable production of efficient, robust and portable devices. We introduce additive manufacturing as a production technique of quantum device components with unrivalled design freedom and rapid prototyping. This provides a step change in efficiency, compactness and facilitates systems integration. As a demonstrator we present an ultrahigh vacuum compatible ultracold atom source dissipating less than ten milliwatts of electrical power during field generation to produce large samples of cold rubidium gases. This disruptive technology opens the door to drastically improved integrated structures, which will further reduce size and assembly complexity in scalable series manufacture of bespoke portable quantum devices.
Collapse
Affiliation(s)
- R Saint
- School of Physics and Astronomy, The University of Nottingham, Nottingham, NG7 2RD, United Kingdom
- Department of Physics and Astronomy, University of Sussex, Brighton, BN1 9QH, United Kingdom
| | - W Evans
- School of Physics and Astronomy, The University of Nottingham, Nottingham, NG7 2RD, United Kingdom
- Department of Physics and Astronomy, University of Sussex, Brighton, BN1 9QH, United Kingdom
| | - Y Zhou
- School of Physics and Astronomy, The University of Nottingham, Nottingham, NG7 2RD, United Kingdom
| | - T Barrett
- School of Physics and Astronomy, The University of Nottingham, Nottingham, NG7 2RD, United Kingdom
- Department of Physics and Astronomy, University of Sussex, Brighton, BN1 9QH, United Kingdom
| | - T M Fromhold
- School of Physics and Astronomy, The University of Nottingham, Nottingham, NG7 2RD, United Kingdom
| | - E Saleh
- Faculty of Engineering, EPSRC Centre for Innovative Manufacturing in Additive Manufacturing, University of Nottingham, Nottingham, United Kingdom
| | - I Maskery
- Faculty of Engineering, EPSRC Centre for Innovative Manufacturing in Additive Manufacturing, University of Nottingham, Nottingham, United Kingdom
| | - C Tuck
- Faculty of Engineering, EPSRC Centre for Innovative Manufacturing in Additive Manufacturing, University of Nottingham, Nottingham, United Kingdom
| | - R Wildman
- Faculty of Engineering, EPSRC Centre for Innovative Manufacturing in Additive Manufacturing, University of Nottingham, Nottingham, United Kingdom
| | - F Oručević
- School of Physics and Astronomy, The University of Nottingham, Nottingham, NG7 2RD, United Kingdom
- Department of Physics and Astronomy, University of Sussex, Brighton, BN1 9QH, United Kingdom
| | - P Krüger
- School of Physics and Astronomy, The University of Nottingham, Nottingham, NG7 2RD, United Kingdom.
- Department of Physics and Astronomy, University of Sussex, Brighton, BN1 9QH, United Kingdom.
| |
Collapse
|
21
|
Louzao I, Koch B, Taresco V, Ruiz-Cantu L, Irvine DJ, Roberts CJ, Tuck C, Alexander C, Hague R, Wildman R, Alexander MR. Identification of Novel "Inks" for 3D Printing Using High-Throughput Screening: Bioresorbable Photocurable Polymers for Controlled Drug Delivery. ACS Appl Mater Interfaces 2018; 10:6841-6848. [PMID: 29322768 DOI: 10.1021/acsami.7b15677] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A robust methodology is presented to identify novel biomaterials suitable for three-dimensional (3D) printing. Currently, the application of additive manufacturing is limited by the availability of functional inks, especially in the area of biomaterials; this is the first time when this method is used to tackle this problem, allowing hundreds of formulations to be readily assessed. Several functional properties, including the release of an antidepressive drug (paroxetine), cytotoxicity, and printability, are screened for 253 new ink formulations in a high-throughput format as well as mechanical properties. The selected candidates with the desirable properties are successfully scaled up using 3D printing into a range of object architectures. A full drug release study and degradability and tensile modulus experiments are presented on a simple architecture to validating the suitability of this methodology to identify printable inks for 3D printing devices with bespoke properties.
Collapse
Affiliation(s)
- Iria Louzao
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| | - Britta Koch
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| | - Vincenzo Taresco
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| | - Laura Ruiz-Cantu
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| | - Derek J Irvine
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| | - Clive J Roberts
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| | - Christopher Tuck
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| | - Cameron Alexander
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| | - Richard Hague
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| | - Ricky Wildman
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| | - Morgan R Alexander
- School of Pharmacy and ‡Faculty of Engineering, University of Nottingham , Nottingham NG7 2RD, U.K
| |
Collapse
|
22
|
Tuck C, Ly E, Bogatyrev A, Costetsou I, Gibson P, Barrett J, Muir J. Fermentable short chain carbohydrate (FODMAP) content of common plant-based foods and processed foods suitable for vegetarian- and vegan-based eating patterns. J Hum Nutr Diet 2018; 31:422-435. [DOI: 10.1111/jhn.12546] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- C. Tuck
- Department of Gastroenterology; Monash University; The Alfred Hospital; Melbourne VIC Australia
| | - E. Ly
- Department of Gastroenterology; Monash University; The Alfred Hospital; Melbourne VIC Australia
| | - A. Bogatyrev
- Department of Gastroenterology; Monash University; The Alfred Hospital; Melbourne VIC Australia
| | - I. Costetsou
- Department of Gastroenterology; Monash University; The Alfred Hospital; Melbourne VIC Australia
| | - P. Gibson
- Department of Gastroenterology; Monash University; The Alfred Hospital; Melbourne VIC Australia
| | - J. Barrett
- Department of Gastroenterology; Monash University; The Alfred Hospital; Melbourne VIC Australia
| | - J. Muir
- Department of Gastroenterology; Monash University; The Alfred Hospital; Melbourne VIC Australia
| |
Collapse
|
23
|
Hu Q, Sun XZ, Parmenter CDJ, Fay MW, Smith EF, Rance GA, He Y, Zhang F, Liu Y, Irvine D, Tuck C, Hague R, Wildman R. Author Correction: Additive manufacture of complex 3D Au-containing nanocomposites by simultaneous two-photon polymerisation and photoreduction. Sci Rep 2018; 8:3512. [PMID: 29459740 PMCID: PMC5818500 DOI: 10.1038/s41598-018-21513-8] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Qin Hu
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom.
| | - Xue-Zhong Sun
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Christopher D J Parmenter
- Nanoscale and Microscale Research Centre, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Michael W Fay
- Nanoscale and Microscale Research Centre, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Emily F Smith
- Nanoscale and Microscale Research Centre, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Graham A Rance
- Nanoscale and Microscale Research Centre, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Yinfeng He
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Fan Zhang
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Yaan Liu
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Derek Irvine
- Department of Chemical and Environmental Engineering, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Christopher Tuck
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Richard Hague
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Ricky Wildman
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom.
| |
Collapse
|
24
|
Keerie C, Tuck C, Milne G, Eldridge S, Wright N, Lewis SC. Data sharing in clinical trials - practical guidance on anonymising trial datasets. Trials 2018; 19:25. [PMID: 29321053 PMCID: PMC5763739 DOI: 10.1186/s13063-017-2382-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/06/2017] [Indexed: 11/10/2022] Open
Abstract
Background There is an increasing demand by non-commercial funders that trialists should provide access to trial data once the primary analysis is completed. This has to take into account concerns about identifying individual trial participants, and the legal and regulatory requirements. Methods Using the good practice guideline laid out by the work funded by the Medical Research Council Hubs for Trials Methodology Research (MRC HTMR), we anonymised a dataset from a recently completed trial. Using this example, we present practical guidance on how to anonymise a dataset, and describe rules that could be used on other trial datasets. We describe how these might differ if the trial was to be made freely available to all, or if the data could only be accessed with specific permission and data usage agreements in place. Results Following the good practice guidelines, we successfully created a controlled access model for trial data sharing. The data were assessed on a case-by-case basis classifying variables as direct, indirect and superfluous identifiers with differing methods of anonymisation assigned depending on the type of identifier. A final dataset was created and checks of the anonymised dataset were applied. Lastly, a procedure for release of the data was implemented to complete the process. Conclusions We have implemented a practical solution to the data anonymisation process resulting in a bespoke anonymised dataset for a recently completed trial. We have gained useful learnings in terms of efficiency of the process going forward, the need to balance anonymity with data utilisation and future work that should be undertaken. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2382-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX, UK.
| | - Christopher Tuck
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | - Garry Milne
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | | | - Neil Wright
- CTSU - Clinical Trial Service Unit and Epidemiological Studies Unit University of Oxford, Oxford, UK
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
| |
Collapse
|
25
|
Hu Q, Sun XZ, Parmenter CDJ, Fay MW, Smith EF, Rance GA, He Y, Zhang F, Liu Y, Irvine D, Tuck C, Hague R, Wildman R. Additive manufacture of complex 3D Au-containing nanocomposites by simultaneous two-photon polymerisation and photoreduction. Sci Rep 2017; 7:17150. [PMID: 29215026 PMCID: PMC5719407 DOI: 10.1038/s41598-017-17391-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [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: 08/01/2017] [Accepted: 11/19/2017] [Indexed: 11/10/2022] Open
Abstract
The fabrication of complex three-dimensional gold-containing nanocomposite structures by simultaneous two-photon polymerisation and photoreduction is demonstrated. Increased salt delivers reduced feature sizes down to line widths as small as 78 nm, a level of structural intricacy that represents a significant advance in fabrication complexity. The development of a general methodology to efficiently mix pentaerythritol triacrylate (PETA) with gold chloride hydrate (HAuCl4∙3H2O) is reported, where the gold salt concentration is adjustable on demand from zero to 20 wt%. For the first-time 7-Diethylamino-3-thenoylcoumarin (DETC) is used as the photoinitiator. Only 0.5 wt% of DETC was required to promote both polymerisation and photoreduction of up to 20 wt% of gold salt. This efficiency is the highest reported for Au-containing composite fabrication by two-photon lithography. Transmission Electron Microscopy (TEM) analysis confirmed the presence of small metallic nanoparticles (5.4 ± 1.4 nm for long axis / 3.7 ± 0.9 nm for short axis) embedded within the polymer matrix, whilst X-ray Photoelectron Spectroscopy (XPS) confirmed that they exist in the zero valent oxidation state. UV-vis spectroscopy defined that they exhibit the property of localised surface plasmon resonance (LSPR). The capability demonstrated in this study opens up new avenues for a range of applications, including plasmonics, metamaterials, flexible electronics and biosensors.
Collapse
Affiliation(s)
- Qin Hu
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom.
| | - Xue-Zhong Sun
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Christopher D J Parmenter
- Nanoscale and Microscale Research Centre, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Michael W Fay
- Nanoscale and Microscale Research Centre, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Emily F Smith
- Nanoscale and Microscale Research Centre, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Graham A Rance
- Nanoscale and Microscale Research Centre, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Yinfeng He
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Fan Zhang
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Yaan Liu
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Derek Irvine
- Department of Chemical and Environmental Engineering, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Christopher Tuck
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Richard Hague
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Ricky Wildman
- Centre for Additive Manufacturing, Faculty of Engineering, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom.
| |
Collapse
|
26
|
Hirsch M, Catchpole-Smith S, Patel R, Marrow P, Li W, Tuck C, Sharples SD, Clare AT. Meso-scale defect evaluation of selective laser melting using spatially resolved acoustic spectroscopy. Proc Math Phys Eng Sci 2017; 473:20170194. [PMID: 28989306 PMCID: PMC5627373 DOI: 10.1098/rspa.2017.0194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 08/11/2017] [Indexed: 11/12/2022] Open
Abstract
Developments in additive manufacturing technology are serving to expand the potential applications. Critical developments are required in the supporting areas of measurement and in process inspection to achieve this. CM247LC is a nickel superalloy that is of interest for use in aerospace and civil power plants. However, it is difficult to process via selective laser melting (SLM) as it suffers from cracking during rapid cooling and solidification. This limits the viability of CM247LC parts created using SLM. To quantify part integrity, spatially resolved acoustic spectroscopy (SRAS) has been identified as a viable non-destructive evaluation technique. In this study, a combination of optical microscopy and SRAS was used to identify and classify the surface defects present in SLM-produced parts. By analysing the datasets and scan trajectories, it is possible to correlate morphological information with process parameters. Image processing was used to quantify porosity and cracking for bulk density measurement. Analysis of surface acoustic wave data showed that an error in manufacture in the form of an overscan occurred. Comparing areas affected by overscan with a bulk material, a change in defect density from 1.17% in the bulk material to 5.32% in the overscan regions was observed, highlighting the need to reduce overscan areas in manufacture.
Collapse
Affiliation(s)
- M Hirsch
- Optics and Photonics Group, University of Nottingham, Nottingham, NG7 2RD, UK.,Advanced Component Engineering Laboratory, University of Nottingham, Nottingham, NG7 2RD, UK
| | - S Catchpole-Smith
- Additive Manufacturing and 3D Printing Research Group, Faculty of Engineering, University of Nottingham, Nottingham, NG7 2RD, UK
| | - R Patel
- Optics and Photonics Group, University of Nottingham, Nottingham, NG7 2RD, UK
| | - P Marrow
- Optics and Photonics Group, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Wenqi Li
- Optics and Photonics Group, University of Nottingham, Nottingham, NG7 2RD, UK
| | - C Tuck
- Additive Manufacturing and 3D Printing Research Group, Faculty of Engineering, University of Nottingham, Nottingham, NG7 2RD, UK
| | - S D Sharples
- Optics and Photonics Group, University of Nottingham, Nottingham, NG7 2RD, UK
| | - A T Clare
- Advanced Component Engineering Laboratory, University of Nottingham, Nottingham, NG7 2RD, UK
| |
Collapse
|
27
|
Abstract
Stent geometries are obtained by topology optimization for minimized compliance under different stenosis levels and plaque material types. Three levels of stenosis by cross-sectional area, i.e., 30%, 40%, and 50% and three different plaque material properties, i.e., calcified, cellular, and hypocellular, were studied. The raw optimization results were converted to clear design concepts and their performance was evaluated by implanting them in their respective stenosed artery types using finite element analysis. The results were compared with a generic stent in similar arteries, which showed that the new designs showed less recoil. This work provides a concept that stents could be tailored to specific lesions in order to minimize recoil and maintain a patent lumen in stenotic arteries.
Collapse
Affiliation(s)
- Muhammad Farhan Khan
- Mem. ASME Department of Mechanical, Materials and Manufacturing Engineering, Faculty of Engineering, University of Nottingham, University Park, Nottingham NG72RD, UK e-mail:
| | - David Brackett
- Department of Mechanical, Materials and Manufacturing Engineering, Faculty of Engineering, University of Nottingham, University Park, Nottingham NG72RD, UK e-mail:
| | - Ian Ashcroft
- Professor Department of Mechanical, Materials and Manufacturing Engineering, Faculty of Engineering, University of Nottingham, University Park, Nottingham NG72RD, UK e-mail:
| | - Christopher Tuck
- Professor Department of Mechanical, Materials and Manufacturing Engineering, Faculty of Engineering, University of Nottingham, University Park, Nottingham NG72RD, UK e-mail:
| | - Ricky Wildman
- Professor Department of Chemical and Environmental Engineering, Faculty of Engineering, University of Nottingham, University Park, Nottingham NG72RD, UK e-mail:
| |
Collapse
|
28
|
Liu Y, Hu Q, Zhang F, Tuck C, Irvine D, Hague R, He Y, Simonelli M, Rance GA, Smith EF, Wildman RD. Additive Manufacture of Three Dimensional Nanocomposite Based Objects through Multiphoton Fabrication. Polymers (Basel) 2016; 8:polym8090325. [PMID: 30974598 PMCID: PMC6431936 DOI: 10.3390/polym8090325] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/27/2016] [Accepted: 08/04/2016] [Indexed: 11/16/2022] Open
Abstract
Three-dimensional structures prepared from a gold-polymer composite formulation have been fabricated using multiphoton lithography. In this process, gold nanoparticles were simultaneously formed through photoreduction whilst polymerisation of two possible monomers was promoted. The monomers, trimethylopropane triacrylate (TMPTA) and pentaerythritol triacrylate (PETA) were mixed with a gold salt, but it was found that the addition of a ruthenium(II) complex enhanced both the geometrical uniformity and integrity of the polymerised/reduced material, enabling the first production of 3D gold-polymer structures by single step multiphoton lithography.
Collapse
Affiliation(s)
- Yaan Liu
- Faculty of Engineering, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - Qin Hu
- Faculty of Engineering, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - Fan Zhang
- Faculty of Engineering, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - Christopher Tuck
- Faculty of Engineering, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - Derek Irvine
- Faculty of Engineering, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - Richard Hague
- Faculty of Engineering, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - Yinfeng He
- Faculty of Engineering, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - Marco Simonelli
- Faculty of Engineering, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - Graham A Rance
- Nanoscale and Microscale Research Centre, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - Emily F Smith
- Nanoscale and Microscale Research Centre, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - Ricky D Wildman
- Faculty of Engineering, The University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| |
Collapse
|
29
|
Abstract
Lattice structures are regarded as excellent candidates for use in lightweight energy-absorbing applications, such as crash protection. In this paper we investigate the crushing behaviour, mechanical properties and energy absorption of lattices made by an additive manufacturing process. Two types of lattice were examined: body-centred-cubic (BCC) and a reinforced variant called BCC z. The lattices were subject to compressive loads in two orthogonal directions, allowing an assessment of their mechanical anisotropy to be made. We also examined functionally graded versions of these lattices, which featured a density gradient along one direction. The graded structures exhibited distinct crushing behaviour, with a sequential collapse of cellular layers preceding full densification. For the BCC z lattice, the graded structures were able to absorb around 114% more energy per unit volume than their non-graded counterparts before full densification, 1371 ± 9 kJ/m3 versus 640 ± 10 kJ/m3. This highlights the strong potential for functionally graded lattices to be used in energy-absorbing applications. Finally, we determined several of the Gibson–Ashby coefficients relating the mechanical properties of lattice structures to their density; these are crucial in establishing the constitutive models required for effective lattice design. These results improve the current understanding of additively manufactured lattices and will enable the design of sophisticated, functional, lightweight components in the future.
Collapse
Affiliation(s)
- Ian Maskery
- Additive Manufacturing & 3D Printing Research Group, Faculty of Engineering, University of Nottingham, UK
| | - Alexandra Hussey
- Additive Manufacturing & 3D Printing Research Group, Faculty of Engineering, University of Nottingham, UK
| | - Ajit Panesar
- Additive Manufacturing & 3D Printing Research Group, Faculty of Engineering, University of Nottingham, UK
| | - Adedeji Aremu
- Additive Manufacturing & 3D Printing Research Group, Faculty of Engineering, University of Nottingham, UK
| | - Christopher Tuck
- Additive Manufacturing & 3D Printing Research Group, Faculty of Engineering, University of Nottingham, UK
| | - Ian Ashcroft
- Additive Manufacturing & 3D Printing Research Group, Faculty of Engineering, University of Nottingham, UK
| | - Richard Hague
- Additive Manufacturing & 3D Printing Research Group, Faculty of Engineering, University of Nottingham, UK
| |
Collapse
|
30
|
Yao C, Tuck C, Barrett J, Canale K, Philpott H, Gibson P. Reproducibility of lactulose and fructose breath hydrogen testing and impact on clinical utility. Journal of Nutrition & Intermediary Metabolism 2016. [DOI: 10.1016/j.jnim.2015.12.258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
31
|
Zhang F, Tuck C, Hague R, He Y, Saleh E, Li Y, Sturgess C, Wildman R. Inkjet printing of polyimide insulators for the 3D printing of dielectric materials for microelectronic applications. J Appl Polym Sci 2016. [DOI: 10.1002/app.43361] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Fan Zhang
- Additive Manufacturing and 3D Printing Research Group; Faculty of Engineering, Nottingham University; Nottingham NG7 2RD United Kingdom
| | - Christopher Tuck
- Additive Manufacturing and 3D Printing Research Group; Faculty of Engineering, Nottingham University; Nottingham NG7 2RD United Kingdom
| | - Richard Hague
- Additive Manufacturing and 3D Printing Research Group; Faculty of Engineering, Nottingham University; Nottingham NG7 2RD United Kingdom
| | - Yinfeng He
- Additive Manufacturing and 3D Printing Research Group; Faculty of Engineering, Nottingham University; Nottingham NG7 2RD United Kingdom
| | - Ehab Saleh
- Additive Manufacturing and 3D Printing Research Group; Faculty of Engineering, Nottingham University; Nottingham NG7 2RD United Kingdom
| | - You Li
- Additive Manufacturing and 3D Printing Research Group; Faculty of Engineering, Nottingham University; Nottingham NG7 2RD United Kingdom
| | - Craig Sturgess
- Additive Manufacturing and 3D Printing Research Group; Faculty of Engineering, Nottingham University; Nottingham NG7 2RD United Kingdom
| | - Ricky Wildman
- Additive Manufacturing and 3D Printing Research Group; Faculty of Engineering, Nottingham University; Nottingham NG7 2RD United Kingdom
| |
Collapse
|
32
|
Gunasekera DHAT, Kuek S, Hasanaj D, He Y, Tuck C, Croft AK, Wildman RD. Three dimensional ink-jet printing of biomaterials using ionic liquids and co-solvents. Faraday Discuss 2016; 190:509-23. [DOI: 10.1039/c5fd00219b] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
1-Ethyl-3-methylimidazolium acetate ([C2C1Im][OAc]) and 1-butyl-3-methylimidazolium acetate ([C4C1Im][OAc]) have been used as solvents for the dissolution and ink-jet printing of cellulose from 1.0 to 4.8 wt%, mixed with the co-solvents 1-butanol and DMSO. 1-Butanol and DMSO were used as rheological modifiers to ensure consistent printing, with DMSO in the range of 41–47 wt% producing samples within the printable range of a DIMATIX print-head used (printability parameter < 10) at 55 °C, whilst maintaining cellulose solubility. Regeneration of cellulose from printed samples using water was demonstrated, with the resulting structural changes to the cellulose sample assessed by scanning electron microscopy (SEM) and white light interferometry (WLI). These results indicate the potential of biorenewable materials to be used in the 3D additive manufacture process to generate single-component and composite materials.
Collapse
Affiliation(s)
| | - SzeLee Kuek
- Faculty of Engineering
- University of Nottingham
- UK
| | | | - Yinfeng He
- Faculty of Engineering
- University of Nottingham
- UK
| | | | | | | |
Collapse
|
33
|
Affiliation(s)
- Maria Lukić
- Department of Materials, Loughborough University; Loughborough, LE11 3TU, Leicestershire, United Kingdom
| | - Jane Clarke
- Department of Materials, Loughborough University; Loughborough, LE11 3TU, Leicestershire, United Kingdom
| | - Christopher Tuck
- Department of Mechanical, Materials and Manufacturing Engineering, Nottingham University, University Park; Nottingham NG7 2RD United Kingdom
| | - William Whittow
- Department of Materials, Loughborough University; Loughborough, LE11 3TU, Leicestershire, United Kingdom
| | - Garry Wells
- Defence Science and Technology Laboratory; Porton down; Salisbury Wiltshire SP4 0JQ United Kingdom
| |
Collapse
|
34
|
Tuck C, Barrett J, Gibson P, Muir J. Utilising cooking methods can reduce the fodmap content of legumes to assist in increasing fibre intake. Journal of Nutrition & Intermediary Metabolism 2014. [DOI: 10.1016/j.jnim.2014.10.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
35
|
|
36
|
Thurecht KJ, Gooden PN, Goel S, Tuck C, Licence P, Irvine DJ. Free-Radical Polymerization in Ionic Liquids: The Case for a Protected Radical. Macromolecules 2008. [DOI: 10.1021/ma7026403] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kristofer J. Thurecht
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, U.K.; School of Chemical and Environmental Engineering, The University of Nottingham, Nottingham, NG7 2RD, U.K.; and Indian Institute of Technology Delhi, Hauz Khas, New Delhi 110 016, India
| | - Peter N. Gooden
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, U.K.; School of Chemical and Environmental Engineering, The University of Nottingham, Nottingham, NG7 2RD, U.K.; and Indian Institute of Technology Delhi, Hauz Khas, New Delhi 110 016, India
| | - Sarika Goel
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, U.K.; School of Chemical and Environmental Engineering, The University of Nottingham, Nottingham, NG7 2RD, U.K.; and Indian Institute of Technology Delhi, Hauz Khas, New Delhi 110 016, India
| | - Christopher Tuck
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, U.K.; School of Chemical and Environmental Engineering, The University of Nottingham, Nottingham, NG7 2RD, U.K.; and Indian Institute of Technology Delhi, Hauz Khas, New Delhi 110 016, India
| | - Peter Licence
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, U.K.; School of Chemical and Environmental Engineering, The University of Nottingham, Nottingham, NG7 2RD, U.K.; and Indian Institute of Technology Delhi, Hauz Khas, New Delhi 110 016, India
| | - Derek J. Irvine
- School of Chemistry, The University of Nottingham, University Park, Nottingham, NG7 2RD, U.K.; School of Chemical and Environmental Engineering, The University of Nottingham, Nottingham, NG7 2RD, U.K.; and Indian Institute of Technology Delhi, Hauz Khas, New Delhi 110 016, India
| |
Collapse
|
37
|
Ong MH, Wagner H, Tuck C, Hague R. Body-fitting customisation of motorcycle seats: an investigation of consumer requirements. ACTA ACUST UNITED AC 2008. [DOI: 10.1504/ijmassc.2008.017149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
38
|
|
39
|
|
40
|
Ginsberg HN, Tuck C. Diabetes and dyslipidemia. Heart Fail Monit 2003; 2:14-20. [PMID: 12634894] [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: 03/01/2023]
Abstract
Numerous prospective cohort studies have indicated that diabetes mellitus (DM), particularly type-2 DM (the type of diabetes associated with insulin resistance that usually strikes adults), is associated with a 3-4-fold increase in risk for coronary heart disease (CHD) [1-3]. The increase in risk is particularly evident in younger-age groups, and in women: females with type-2 DM appear to lose a great deal of the protection that characterizes non-diabetic females. Furthermore, patients with DM have a 50% greater in-hospital mortality, and a 2-fold increased rate of death within 2 years of surviving a myocardial infarction. Overall, CHD is the leading cause of death in individuals with DM who are >35 years old. Although a significant portion of this increased risk is associated with the presence of well-characterized risk factors for CHD, a significant proportion remains unexplained. Patients with DM, particularly those with type-2 DM, have abnormal plasma lipid and lipoprotein concentrations that are less commonly present in non-diabetics [4-6]. Patients with poorly controlled type-1 DM can also have a dyslipidemic pattern, but, in this review, we will focus on the dyslipidemia seen commonly in patients with type-2 DM. In particular, we will describe the pathophysiology underlying the increase in plasma very low-density lipoprotein triglyceride levels, the reductions in plasma high-density lipoprotein cholesterol levels, and the abnormal, small, dense low-density lipoproteins that are the central components of diabetic dyslipidemia. The dyslipidemia of DM clearly adds significantly to the high risk for CHD in this group, and must be treated aggressively with diet, weight loss and lipid-altering medications. Combinations of lipid-altering medications, particularly statins and fibrates, can markedly change plasma lipid levels, often bringing them all into the normal range.
Collapse
Affiliation(s)
- H N Ginsberg
- College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA
| | | |
Collapse
|
41
|
Affiliation(s)
- H N Ginsberg
- College of Physicians and Surgeons of Columbia University, Department of Medicine, 630 West 168th Street, New York, NY 10032, USA.
| | | |
Collapse
|
42
|
Sacco RL, Benson RT, Kargman DE, Boden-Albala B, Tuck C, Lin IF, Cheng JF, Paik MC, Shea S, Berglund L. High-density lipoprotein cholesterol and ischemic stroke in the elderly: the Northern Manhattan Stroke Study. JAMA 2001; 285:2729-35. [PMID: 11386928 DOI: 10.1001/jama.285.21.2729] [Citation(s) in RCA: 269] [Impact Index Per Article: 11.7] [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: 11/14/2022]
Abstract
CONTEXT Elevated high-density lipoprotein cholesterol (HDL-C) levels have been shown to be protective against cardiovascular disease. However, the association of specific lipoprotein classes and ischemic stroke has not been well defined, particularly in higher-risk minority populations. OBJECTIVE To evaluate the association between HDL-C and ischemic stroke in an elderly, racially or ethnically diverse population. DESIGN Population-based, incident case-control study conducted July 1993 through June 1997. SETTING A multiethnic community in northern Manhattan, New York, NY. PARTICIPANTS Cases (n = 539) of first ischemic stroke (67% aged >/=65 years; 55% women; 53% Hispanic, 28% black, and 19% white) were enrolled and matched by age, sex, and race or ethnicity to stroke-free community residents (controls; n = 905). MAIN OUTCOME MEASURE Independent association of fasting HDL-C levels, determined at enrollment, with ischemic stroke, including atherosclerotic and nonatherosclerotic ischemic stroke subtypes. RESULTS After risk factor adjustment, a protective effect was observed for HDL-C levels of at least 35 mg/dL (0.91 mmol/L) (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.39-0.72). A dose-response relationship was observed (OR, 0.65; 95% CI, 0.47-0.90 and OR, 0.31; 95% CI, 0.21-0.46) for HDL-C levels of 35 to 49 mg/dL (0.91-1.28 mmol/L) and at least 50 mg/dL (1.29 mmol/L), respectively. The protective effect of a higher HDL-C level was significant among participants aged 75 years or older (OR, 0.51; 95% CI, 0.27-0.94), was more potent for the atherosclerotic stroke subtype (OR, 0.20; 95% CI, 0.08-0.50), and was present in all 3 racial or ethnic groups studied. CONCLUSIONS Increased HDL-C levels are associated with reduced risk of ischemic stroke in the elderly and among different racial or ethnic groups. These data add to the evidence relating lipids to stroke and support HDL-C as an important modifiable stroke risk factor.
Collapse
Affiliation(s)
- R L Sacco
- Neurological Institute, 710 W 168 St, New York, NY 10032, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Kargman DE, Tuck C, Berglund L, Lin IF, Mukherjee RS, Thompson EV, Jones J, Boden-Albala B, Paik MC, Sacco RL. Lipid and lipoprotein levels remain stable in acute ischemic stroke: the Northern Manhattan Stroke Study. Atherosclerosis 1998; 139:391-9. [PMID: 9712347 DOI: 10.1016/s0021-9150(98)00085-9] [Citation(s) in RCA: 60] [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: 12/01/2022]
Abstract
Serum lipoproteins including lipoprotein(a), Lp(a), are emerging as possible biological markers for cerebrovascular disease. Existing data on Lp(a) and serum lipids levels following acute ischemic stroke (AIS) are however equivocal. To determine whether serum Lp(a) and other lipid levels obtained within 24 h of acute ischemic stroke onset changed over the ensuing 4 weeks and whether these levels are related to an acute phase response, acquired nutritional deficiency, and neurovascular data, we conducted repeated measurement analyses among 19 subjects (mean age 65.0 +/- 12.1 years; 32% women) presenting with AIS (evaluated within 9.7 +/- 12.7 h). Eleven of the subjects had a moderate-to-severe stroke, defined by NIH stroke severity scale, and seven patients had a large cerebral infarction. Seven serial measurements of Lp(a), total cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, and other lipoproteins, major acute phase reactants and albumin levels were collected for each subject over 4 weeks. The mean initial levels, (mg/dl), of total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, Lp(a), apolipoproteins A-I and B were: 225 +/- 57.6, 154 +/- 56.0, 40 +/- 10.4, 181 +/- 93.7, 52 +/- 28.6, 130 +/- 24.6, and 141 +/- 46.1, respectively. There were no significant changes in mean serum lipid, apolipoprotein or Lp(a) levels over the 4-week study period, analyzed by a random effects model to test for time trend. In addition, there were no significant changes in established acute phase or nutritional markers (C-reactive protein, alpha 1-glycoprotein, haptoglobin or serum albumin). Our findings suggest that serum lipid, apolipoprotein and Lp(a) levels remain stable following AIS, consistent with the absence of acute phase response or nutritional deficiency.
Collapse
Affiliation(s)
- D E Kargman
- Department of Neurology, Columbia-Presbyterian Medical Center, New York, NY 10032, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|