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Crooks CJ, West J, Morling JR, Simmonds M, Juurlink I, Cruickshank S, Briggs S, Hammond-Pears S, Shaw D, Card TR, Fogarty AW. Pulse oximetry has limited utility in identifying potential patients for long-term oxygen therapy. Int J Tuberc Lung Dis 2024; 28:253-255. [PMID: 38659138 DOI: 10.5588/ijtld.23.0491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Affiliation(s)
- C J Crooks
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK, Nottingham University Hospitals NHS Trust, UK
| | - J West
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK, Nottingham University Hospitals NHS Trust, UK, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK, East Midlands Academic Health Science Network, University of Nottingham, Nottingham, UK
| | - J R Morling
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - M Simmonds
- Nottingham University Hospitals NHS Trust, UK
| | - I Juurlink
- Nottingham University Hospitals NHS Trust, UK
| | | | - S Briggs
- Nottingham University Hospitals NHS Trust, UK
| | - S Hammond-Pears
- Nottingham University Hospitals NHS Trust, UK, East Midlands Academic Health Science Network, University of Nottingham, Nottingham, UK
| | - D Shaw
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK, Division of Respiratory Medicine, School of Medicine, University of Nottingham, Nottingham
| | - T R Card
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK, Nottingham University Hospitals NHS Trust, UK, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - A W Fogarty
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK, Nottingham University Hospitals NHS Trust, UK, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
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Rakkar K, Pang YL, Rajasekar P, Portelli MA, Hall RJ, Clifford RL, Shaw D, Sayers I. Mepolizumab Induced Changes in Nasal Methylome and Transcriptome to Predict Response in Asthma. Am J Respir Crit Care Med 2024. [PMID: 38386780 DOI: 10.1164/rccm.202308-1477le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 02/22/2024] [Indexed: 02/24/2024] Open
Affiliation(s)
- Kamini Rakkar
- University of Nottingham, 6123, Nottingham, United Kingdom of Great Britain and Northern Ireland;
| | - Yik L Pang
- University of Nottingham, 6123, Nottingham, United Kingdom of Great Britain and Northern Ireland
| | - Poojitha Rajasekar
- University of Nottingham, 6123, Nottingham, United Kingdom of Great Britain and Northern Ireland
| | - Michael A Portelli
- University of Nottingham, Translational Medical Sciences, Nottingham Biomedical Research Centre, Nottingham, Nottinghamshire, United Kingdom of Great Britain and Northern Ireland
| | - Robert J Hall
- University of Nottingham, 6123, Nottingham, United Kingdom of Great Britain and Northern Ireland
| | - Rachel L Clifford
- University of Nottingham, Nottingham, United Kingdom of Great Britain and Northern Ireland
| | - Dominick Shaw
- University of Nottingham, Respiratory Research Unit, Nottingham, United Kingdom of Great Britain and Northern Ireland
| | - Ian Sayers
- University of Nottingham, Division of Therapeutics & Molecular Medicine, Nottingham, United Kingdom of Great Britain and Northern Ireland
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Gonem S, Lemberger J, Baguneid A, Briggs S, McKeever TM, Shaw D. Real-world implementation of the National Early Warning Score-2 in an acute respiratory unit. BMJ Open Respir Res 2024; 11:e002095. [PMID: 38296608 PMCID: PMC10831462 DOI: 10.1136/bmjresp-2023-002095] [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] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION The National Early Warning Score-2 (NEWS-2) is used to detect deteriorating patients in hospital settings. We aimed to understand how NEWS-2 functions in the real-life setting of an acute respiratory unit. METHODS Clinical observations data were extracted for adult patients (age ≥18 years), admitted under the care of respiratory medicine services from July to December 2019, who had at least one recorded task relating to clinical deterioration. The timing and nature of urgent out-of-hours medical reviews (escalations) were extracted through manual review of the case notes. RESULTS The data set comprised 765 admission episodes (48.9% women) with a mean (SD) age of 69.3 (14.8). 8971 out of 35 991 out-of-hours observation sets (24.9%) had a NEWS-2 ≥5, and 586 of these (6.5%) led to an escalation. Out of 687 escalations, 101 (14.7%) were associated with observation sets with NEWS-2<5. Rising oxygen requirement and extreme values of individual observations were associated with an increased risk of escalation. 57.6% of escalations resulted in a change in treatment. Inpatient mortality was higher in patients who were escalated at least once, compared with those who were not escalated. CONCLUSIONS Most observation sets with NEWS-2 scores ≥5 did not lead to a medical escalation in an acute respiratory setting out-of-hours, but more than half of escalations resulted in a change in treatment. Rising oxygen requirement is a key indicator of respiratory patient acuity which appears to influence the decision to request urgent out-of-hours medical reviews.
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Affiliation(s)
- Sherif Gonem
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Joseph Lemberger
- Department of Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Abdulla Baguneid
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steve Briggs
- Digital and Information, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tricia M McKeever
- Lifespan and Population Health, University of Nottingham, Nottingham, UK
| | - Dominick Shaw
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
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Portelli MA, Bhaker S, Pang V, Bates DO, Johnson SR, Mazar AP, Shaw D, Brightling C, Sayers I. Elevated PLAUR is observed in the airway epithelium of asthma patients and blocking improves barrier integrity. Clin Transl Allergy 2023; 13:e12293. [PMID: 37876037 PMCID: PMC10542610 DOI: 10.1002/clt2.12293] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/10/2023] [Accepted: 07/31/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Expression of the urokinase plasminogen activator receptor (uPAR) is elevated in the airway epithelium in asthma; however, the contribution of uPAR to asthma pathogenesis and scope for therapeutic targeting remains unknown. OBJECTIVES To determine (i) the expression profile of uPAR in cultured human bronchial epithelial cells (HBEC) from asthma patients, (ii) the relationship between uPAR and the epithelial barrier, including blocking uPAR functions and (iii) the function of different uPAR isoforms. METHODS uPAR levels in HBECs isolated from asthma patients and cells at air liquid interface (ALI) during differentiation were quantified. Transepithelial electrical resistance or electrical cell impedance sensing was used to relate uPAR levels to barrier properties, including effects of uPAR blocking antibodies. The functional effects of gain of function was determined using transcriptomics, in cells over-expressing membrane (muPAR), soluble cleaved (scuPAR) or soluble spliced (ssuPAR) isoforms. RESULTS Elevated expression of uPAR was a feature of cultured HBECs from asthma patients, suggesting intrinsic alterations in asthma patient cells. Soluble uPAR levels inversely correlated with barrier properties of the HBEC layer in 2D and ALI. Blocking uPAR-integrin interactions enhanced barrier formation. The gain of function cells showed limited transcriptomic changes. CONCLUSION This study provides a significant advance in our understanding of the relationship between asthma, uPAR and the epithelial barrier, where elevated circulating uPAR results in a reduced cell barrier, a phenotype prevalent in asthma.
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Affiliation(s)
- Michael A. Portelli
- Centre for Respiratory ResearchNIHR Respiratory Biomedical Research CentreSchool of MedicineBiodiscovery InstituteUniversity ParkUniversity of NottinghamNottinghamUK
| | - Sangita Bhaker
- Centre for Respiratory ResearchNIHR Respiratory Biomedical Research CentreSchool of MedicineBiodiscovery InstituteUniversity ParkUniversity of NottinghamNottinghamUK
| | - Vincent Pang
- Tumour Vascular Biology GroupBiodiscovery InstituteUniversity ParkUniversity of NottinghamNottinghamUK
| | - David O. Bates
- Tumour Vascular Biology GroupBiodiscovery InstituteUniversity ParkUniversity of NottinghamNottinghamUK
| | - Simon R. Johnson
- Centre for Respiratory ResearchNIHR Respiratory Biomedical Research CentreSchool of MedicineBiodiscovery InstituteUniversity ParkUniversity of NottinghamNottinghamUK
| | - Andrew P. Mazar
- Department of PharmacologyFeinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Dominick Shaw
- Centre for Respiratory ResearchNIHR Respiratory Biomedical Research CentreSchool of MedicineBiodiscovery InstituteUniversity ParkUniversity of NottinghamNottinghamUK
| | - Christopher Brightling
- Department of Respiratory MedicineUniversity of LeicesterUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | - Ian Sayers
- Centre for Respiratory ResearchNIHR Respiratory Biomedical Research CentreSchool of MedicineBiodiscovery InstituteUniversity ParkUniversity of NottinghamNottinghamUK
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5
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Crooks CJ, West J, Morling JR, Simmonds M, Juurlink I, Briggs S, Cruickshank S, Hammond-Pears S, Shaw D, Card TR, Marshall CR, Fogarty AW. Respiratory rate responses to both hypercapnia and acidaemia are modified by age in patients with acidosis. Respir Physiol Neurobiol 2023:104098. [PMID: 37399900 DOI: 10.1016/j.resp.2023.104098] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/06/2023] [Accepted: 06/25/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To explore the associations between arterial pO2, pCO2 and pH and how these are modified by age. METHODS An analysis of 2598 patients admitted with a diagnosis of Covid-19 infection to a large UK teaching hospital. RESULTS There were inverse associations for arterial pO2, pCO2 and pH with respiratory rate. The effects of pCO2 and pH on respiratory rate were modified by age; older patients had higher respiratory rates at higher pCO2 (p=0.004) and lower pH (p=0.007) values. CONCLUSIONS This suggests that ageing is associated with complex changes in the physiological feedback loops that control respiratory rate. As well as having clinical relevance, this may also impact on the use of respiratory rate in early warning scores across the age range.
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Affiliation(s)
- Colin J Crooks
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, NG7 2UH; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, NG7 2UH; Nottingham University Hospitals NHS Trust, NG7 2UH
| | - Joe West
- Lifespan and Population Health, School of Medicine, University of Nottingham, NG5 1PB; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, NG7 2UH; Nottingham University Hospitals NHS Trust, NG7 2UH; East Midlands Academic Health Science Network, University of Nottingham, Nottingham, NG7 2TU
| | - Joanne R Morling
- Lifespan and Population Health, School of Medicine, University of Nottingham, NG5 1PB; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, NG7 2UH; Nottingham University Hospitals NHS Trust, NG7 2UH
| | | | | | - Steve Briggs
- Nottingham University Hospitals NHS Trust, NG7 2UH
| | | | - Susan Hammond-Pears
- Nottingham University Hospitals NHS Trust, NG7 2UH; East Midlands Academic Health Science Network, University of Nottingham, Nottingham, NG7 2TU
| | - Dominick Shaw
- Nottingham University Hospitals NHS Trust, NG7 2UH; Division of Respiratory Medicine, School of Medicine, University of Nottingham, NG5 1PB
| | - Timothy R Card
- Lifespan and Population Health, School of Medicine, University of Nottingham, NG5 1PB; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, NG7 2UH; Nottingham University Hospitals NHS Trust, NG7 2UH
| | - Charles R Marshall
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, EC1M 6BQ
| | - Andrew W Fogarty
- Lifespan and Population Health, School of Medicine, University of Nottingham, NG5 1PB; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, NG7 2UH; Nottingham University Hospitals NHS Trust, NG7 2UH.
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6
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Crooks CJ, West J, Gazis T, Simmonds M, Shaw D, Card TR, Fogarty AW. Maximal temperature varies by sex and ethnic group in hospital in-patients with Covid-19 infection. J Med Virol 2023; 95:e28837. [PMID: 37303254 DOI: 10.1002/jmv.28837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Colin J Crooks
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joe West
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- East Midlands Academic Health Science Network, University of Nottingham, Nottingham, UK
| | - Tasso Gazis
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark Simmonds
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dominick Shaw
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Division of Respiratory Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Timothy R Card
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Andrew W Fogarty
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
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Crooks CJ, West J, Morling JR, Simmonds M, Juurlink I, Briggs S, Cruickshank S, Hammond-Pears S, Shaw D, Card TR, Fogarty AW. Anaemia of acute inflammation: a higher acute systemic inflammatory response is associated with a larger decrease in blood haemoglobin levels in patients with COVID-19 infection. Clin Med (Lond) 2023; 23:201-205. [PMID: 37197805 PMCID: PMC11046552 DOI: 10.7861/clinmed.2022-0436] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
AIMS The study tests the hypothesis that a higher acute systemic inflammatory response was associated with a larger decrease in blood hemoglobin levels in patients with Coronavirus 2019 (COVID-19) infection. METHODS All patients with either suspected or confirmed COVID-19 infection admitted to a busy UK hospital from February 2020 to December 2021 provided data for analysis. The exposure of interest was maximal serum C-reactive protein (CRP) level after COVID-19 during the same admission. RESULTS A maximal serum CRP >175mg/L was associated with a decrease in blood haemoglobin (-5.0 g/L, 95% confidence interval: -5.9 to -4.2) after adjustment for covariates, including the number of times blood was drawn for analysis.Clinically, for a 55-year-old male patient with a maximum haemoglobin of 150 g/L who was admitted for a 28-day admission, a peak CRP >175 mg/L would be associated with an 11 g/L decrease in blood haemoglobin, compared with only 6 g/L if the maximal CRP was <4 mg/L. CONCLUSIONS A higher acute systemic inflammatory response is associated with larger decreases in blood haemoglobin levels in patients with COVID-19. This represents an example of anaemia of acute inflammation, and a potential mechanism by which severe disease can increase morbidity and mortality.
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Affiliation(s)
| | - Joe West
- University of Nottingham, Nottingham, UK
| | | | - Mark Simmonds
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Irene Juurlink
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steve Briggs
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Abstract
Asthma is one of the most common chronic non-communicable diseases worldwide and is characterised by variable airflow obstruction, causing dyspnoea and wheezing. Highly effective therapies are available; asthma morbidity and mortality have vastly improved in the past 15 years, and most patients can attain good asthma control. However, undertreatment is still common, and improving patient and health-care provider understanding of when and how to adjust treatment is crucial. Asthma management consists of a cycle of assessment of asthma control and risk factors and adjustment of medications accordingly. With the introduction of biological therapies, management of severe asthma has entered the precision medicine era-a shift that is driving clinical ambitions towards disease remission. Patients with severe asthma often have co-existing conditions contributing to their symptoms, mandating a multidimensional management approach. In this Seminar, we provide a clinically focused overview of asthma; epidemiology, pathophysiology, diagnosis, and management in children and adults.
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Affiliation(s)
- Celeste Porsbjerg
- Department of Respiratory and Infectious Diseases, Bispebjerg Hospital, Copenhagen, Denmark; Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Erik Melén
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet and Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Dominick Shaw
- National Institute for Health and Care Research Nottingham Biomedical Research Centre, Division of Respiratory Medicine, School of Medicine, University of Nottingham, Nottingham, UK
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Crooks CJ, West J, Morling J, Simmonds M, Juurlink I, Briggs S, Cruickshank S, Hammond-Pears S, Shaw D, Card T, Fogarty AW. Inverse association between blood pressure and pulse oximetry accuracy: an observational study in patients with suspected or confirmed COVID-19 infection. Emerg Med J 2023; 40:216-220. [PMID: 36600468 DOI: 10.1136/emermed-2022-212443] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pulse oximeters are a standard non-invasive tool to measure blood oxygen levels, and are used in multiple healthcare settings. It is important to understand the factors affecting their accuracy to be able to use them optimally and safely. This analysis aimed to explore the association of the measurement error of pulse oximeters with systolic BP, diastolic BP and heart rate (HR) within ranges of values commonly observed in clinical practice. METHODS The study design was a retrospective observational study of all patients admitted to a large teaching hospital with suspected or confirmed COVID-19 infection from February 2020 to December 2021. Data on systolic and diastolic BPs and HR levels were available from the same time period as the pulse oximetry measurements. RESULTS Data were available for 3420 patients with 5927 observations of blood oxygen saturations as measured by pulse oximetry and ABG sampling within 30 min. The difference in oxygen saturation using the paired pulse oximetry and arterial oxygen saturation difference measurements was inversely associated with systolic BP, increasing by 0.02% with each mm Hg decrease in systolic BP (95% CI 0.00% to 0.03%) over a range of 80-180 mm Hg. Inverse associations were also observed between the error for oxygen saturation as measured by pulse oximetry and with both diastolic BP (+0.03%; 95% CI 0.00% to 0.05%) and HR (+0.04%; 95% CI 0.02% to 0.06% for each unit decrease in the HR). CONCLUSIONS Care needs to be taken in interpreting pulse oximetry measurements in patients with lower systolic and diastolic BPs, and HRs, as oxygen saturation is overestimated as BP and HR decrease. Confirmation of the oxygen saturation with an ABG may be appropriate in some clinical scenarios.
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Affiliation(s)
- Colin J Crooks
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Joe West
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jo Morling
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Mark Simmonds
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Irene Juurlink
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steve Briggs
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Dominick Shaw
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tim Card
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Andrew W Fogarty
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
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Crooks CJ, West J, Morling JR, Simmonds M, Juurlink I, Briggs S, Cruickshank S, Hammond-Pears S, Shaw D, Card TR, Fogarty AW. Differential pulse oximetry readings between ethnic groups and delayed transfer to intensive care units. QJM 2023; 116:63-67. [PMID: 36066450 PMCID: PMC9928225 DOI: 10.1093/qjmed/hcac218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pulse oximeters are widely used to monitor blood oxygen saturations, although concerns exist that they are less accurate in individuals with pigmented skin. AIMS This study aimed to determine if patients with pigmented skin were more severely unwell at the period of transfer to intensive care units (ICUs) than individuals with White skin. METHODS Using data from a large teaching hospital, measures of clinical severity at the time of transfer of patients with COVID-19 infection to ICUs were assessed, and how this varied by ethnic group. RESULTS Data were available on 748 adults. Median pulse oximetry demonstrated similar oxygen saturations at the time of transfer to ICUs (Kruskal-Wallis test, P = 0.51), although median oxygen saturation measurements from arterial blood gases at this time demonstrated lower oxygen saturations in patients classified as Indian/Pakistani ethnicity (91.6%) and Black/Mixed ethnicity (93.0%), compared to those classified as a White ethnicity (94.4%, Kruskal-Wallis test, P = 0.005). There were significant differences in mean respiratory rates in these patients (P < 0.0001), ranging from 26 breaths/min in individuals with White ethnicity to 30 breaths/min for those classified as Indian/Pakistani ethnicity and 31 for those who were classified as Black/Mixed ethnicity. CONCLUSIONS These data are consistent with the hypothesis that differential measurement error for pulse oximeter readings negatively impact on the escalation of clinical care in individuals from other than White ethnic groups. This has implications for healthcare in Africa and South-East Asia and may contribute to differences in health outcomes across ethnic groups globally.
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Affiliation(s)
- C J Crooks
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham NG7 2UH, UK
- Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - J West
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham NG7 2UH, UK
- Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
- East Midlands Academic Health Science Network, University of Nottingham, Nottingham NG7 2TU, UK
| | - J R Morling
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham NG7 2UH, UK
- Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - M Simmonds
- Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - I Juurlink
- Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - S Briggs
- Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - S Cruickshank
- Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - S Hammond-Pears
- Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
- East Midlands Academic Health Science Network, University of Nottingham, Nottingham NG7 2TU, UK
| | - D Shaw
- Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
- Division of Respiratory Medicine, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - T R Card
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham NG7 2UH, UK
- Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - A W Fogarty
- Address correspondence to Dr A.W. Fogarty, NIHR Nottingham Biomedical Research Centre (BRC), Nottingham City Hospital, Nottingham NG5 1PB, UK.
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Fogarty AW, Card T, Shaw D, West J, Simmonds M, Crooks CJ. Error in respiratory rate measurement by direct observation impacts on clinical early warning score algorithms. J Accid Emerg Med 2022; 40:458-459. [PMID: 36456170 DOI: 10.1136/emermed-2022-212689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/05/2022]
Affiliation(s)
- Andrew W Fogarty
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tim Card
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Dominick Shaw
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Joe West
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Mark Simmonds
- Nottingham Universities Hospitals NHS Trust, Nottingham, UK
| | - Colin J Crooks
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
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12
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Forster S, McKeever TM, Shaw D. Effect of implementing the NEWS2 escalation protocol in a large acute NHS trust: a retrospective cohort analysis of mortality, workload and ability of early warning score to predict death within 24 hours. BMJ Open 2022; 12:e064579. [PMID: 36424101 PMCID: PMC9693871 DOI: 10.1136/bmjopen-2022-064579] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To describe the inpatient population, establish patterns in admission and mortality over a 4-year period in different cohorts and assess the prognostic ability and workload implications of introducing the National Early Warning Score 2 (NEWS2) and associated escalation protocol. DESIGN Retrospective cohort analyses of medical and surgical inpatient admissions. SETTING Large teaching hospital with tertiary inpatient care and a major trauma centre employing an electronic observations platform, initially with a local early warning score, followed by NEWS2 introduction in June 2019. PARTICIPANTS 332 682 adult patients were admitted between 1 January 2016 and 31 December 2019. OUTCOME MEASURES Mortality, workload and ability of early warning score to predict death within 24 hours. RESULTS Admissions rose by 19% from 76 055 in 2016 to 90 587 in 2019. Total bed days rose by 10% from 433 382 to 477 485. Mortality fell from 3.7% to 3.1% and was significantly lower in patients discharged from a surgical specialty, 1.0%-1.2% (p<0.001). Total observations recorded increased by 14% from 1 976 872 in 2016 to 2 249 118 in 2019. 65% of observations were attributable to patients under medical specialties, 34% to patients under surgical specialties. Recorded escalations to the registrar were stable from January 2016 to May 2019 but trebled following the introduction of NEWS2 in June 2019. CONCLUSIONS There was an increase in hospital inpatient activity between 2016 and 2019, associated with a reduction in mortality and percentage of observations calculated as reaching threshold NEWS2 score of 7 for escalation to the registrar. The introduction of the NEWS2, with a higher sensitivity and lower specificity, when allied to its escalation protocol, was associated with a significant increase in actual recorded escalations to the registrar. This was more marked in the surgical population and would support refining threshold scores based on admission characteristics when developing the next iteration of NEWS.
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Affiliation(s)
- Sarah Forster
- Respiratory Medicine, University of Nottingham School of Medicine, Nottingham, UK
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Dominick Shaw
- Respiratory Medicine, University of Nottingham School of Medicine, Nottingham, UK
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
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13
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Crooks CJ, West J, Morling JR, Simmonds M, Juurlink I, Briggs S, Cruickshank S, Hammond-Pears S, Shaw D, Card TR, Fogarty AW. Pulse oximeter measurement error of oxygen saturation in patients with SARS-CoV-2 infection stratified by smoking status. Eur Respir J 2022; 60:13993003.01190-2022. [PMID: 36229052 PMCID: PMC9558426 DOI: 10.1183/13993003.01190-2022] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/26/2022] [Indexed: 01/11/2023]
Abstract
As pulse oximeters are now so widely used, it is important to identify any patient groups in whom they may also have a systematic bias that may impair the delivery of medical care to these individuals. One group would be tobacco smokers [1–3], as the inhaled carbon monoxide modifies the haemoglobin molecule within 1–2 min of inhaling tobacco smoke [4], and the subsequent increase in blood carboxyhaemoglobin levels modifies the pulse oximetry signal [5]. This was reported in a series of 16 patients with carbon monoxide poisoning from 1994 which resulted in higher pulse oximetry measurements than the true values, with the comment that this phenomenon may also extend to oxygen saturation measured in smokers as well [6]. To date, no robust real-world clinical data on acutely unwell patients exist to clarify the impact of smoking status and blood carboxyhaemoglobin levels on the measurement error of oxygen saturation by pulse oximeters. There is substantial measurement error in pulse oximetry readings of oxygen saturation below 90% which is not due to smoking status https://bit.ly/3RunKtL
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Affiliation(s)
- Colin J. Crooks
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK,NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joe West
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham University Hospitals NHS Trust, Nottingham, UK,Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK,East Midlands Academic Health Science Network, University of Nottingham, Nottingham, UK
| | - Joanne R. Morling
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham University Hospitals NHS Trust, Nottingham, UK,Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Mark Simmonds
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Irene Juurlink
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steve Briggs
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Susan Hammond-Pears
- Nottingham University Hospitals NHS Trust, Nottingham, UK,East Midlands Academic Health Science Network, University of Nottingham, Nottingham, UK
| | - Dominick Shaw
- Nottingham University Hospitals NHS Trust, Nottingham, UK,NIHR Biomedical Respiratory Research Centre University of Nottingham, Nottingham, UK
| | - Timothy R. Card
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham University Hospitals NHS Trust, Nottingham, UK,Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Andrew W. Fogarty
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham University Hospitals NHS Trust, Nottingham, UK,Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK,Andrew W. Fogarty ()
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14
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Forster S, McKeever TM, Churpek M, Gonem S, Shaw D. Predicting outcome in acute respiratory admissions using patterns of National Early Warning Scores. Clin Med (Lond) 2022; 22:409-415. [PMID: 38589061 PMCID: PMC9595013 DOI: 10.7861/clinmed.2022-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS Accurately predicting risk of patient deterioration is vital. Altered physiology in chronic disease affects the prognostic ability of vital signs based early warning score systems. We aimed to assess the potential of early warning score patterns to improve outcome prediction in patients with respiratory disease. METHODS Patients admitted under respiratory medicine between April 2015 and March 2017 had their National Early Warning Score 2 (NEWS2) calculated retrospectively from vital sign observations. Prediction models (including temporal patterns) were constructed and assessed for ability to predict death within 24 hours using all observations collected not meeting exclusion criteria. The best performing model was tested on a validation cohort of admissions from April 2017 to March 2019. RESULTS The derivation cohort comprised 7,487 admissions and the validation cohort included 8,739 admissions. Adding the maximum score in the preceding 24 hours to the most recently recorded NEWS2 improved area under the receiver operating characteristic curve for death in 24 hours from 0.888 (95% confidence interval (CI) 0.881-0.895) to 0.902 (95% CI 0.895-0.909) in the overall respiratory population. CONCLUSION Combining the most recently recorded score and the maximum NEWS2 score from the preceding 24 hours demonstrated greater accuracy than using snapshot NEWS2. This simple inclusion of a scoring pattern should be considered in future iterations of early warning scoring systems.
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Affiliation(s)
- Sarah Forster
- Nottingham University Hospitals NHS Trust, Nottingham, UK and University of Nottingham School of Medicine, Nottingham, UK.
| | | | - Matthew Churpek
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, USA
| | - Sherif Gonem
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dominick Shaw
- Nottingham University Hospitals NHS Trust, Nottingham, UK and University of Nottingham School of Medicine, Nottingham, UK
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15
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Gonem S, Taylor A, Figueredo G, Forster S, Quinlan P, Garibaldi JM, McKeever TM, Shaw D. Dynamic early warning scores for predicting clinical deterioration in patients with respiratory disease. Respir Res 2022; 23:203. [PMID: 35953815 PMCID: PMC9367123 DOI: 10.1186/s12931-022-02130-6] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background The National Early Warning Score-2 (NEWS-2) is used to detect patient deterioration in UK hospitals but fails to take account of the detailed granularity or temporal trends in clinical observations. We used data-driven methods to develop dynamic early warning scores (DEWS) to address these deficiencies, and tested their accuracy in patients with respiratory disease for predicting (1) death or intensive care unit admission, occurring within 24 h (D/ICU), and (2) clinically significant deterioration requiring urgent intervention, occurring within 4 h (CSD). Methods Clinical observations data were extracted from electronic records for 31,590 respiratory in-patient episodes from April 2015 to December 2020 at a large acute NHS Trust. The timing of D/ICU was extracted for all episodes. 1100 in-patient episodes were annotated manually to record the timing of CSD, defined as a specific event requiring a change in treatment. Time series features were entered into logistic regression models to derive DEWS for each of the clinical outcomes. Area under the receiver operating characteristic curve (AUROC) was the primary measure of model accuracy. Results AUROC (95% confidence interval) for predicting D/ICU was 0.857 (0.852–0.862) for NEWS-2 and 0.906 (0.899–0.914) for DEWS in the validation data. AUROC for predicting CSD was 0.829 (0.817–0.842) for NEWS-2 and 0.877 (0.862–0.892) for DEWS. NEWS-2 ≥ 5 had sensitivity of 88.2% and specificity of 54.2% for predicting CSD, while DEWS ≥ 0.021 had higher sensitivity of 93.6% and approximately the same specificity of 54.3% for the same outcome. Using these cut-offs, 315 out of 347 (90.8%) CSD events were detected by both NEWS-2 and DEWS, at the time of the event or within the previous 4 h; 12 (3.5%) were detected by DEWS but not by NEWS-2, while 4 (1.2%) were detected by NEWS-2 but not by DEWS; 16 (4.6%) were not detected by either scoring system. Conclusion We have developed DEWS that display greater accuracy than NEWS-2 for predicting clinical deterioration events in patients with respiratory disease. Prospective validation studies are required to assess whether DEWS can be used to reduce missed deteriorations and false alarms in real-life clinical settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02130-6.
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Affiliation(s)
- Sherif Gonem
- Department of Respiratory Medicine, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB, UK. .,NIHR Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Adam Taylor
- Digital Research Service, University of Nottingham, Nottingham, UK
| | - Grazziela Figueredo
- Digital Research Service, University of Nottingham, Nottingham, UK.,School of Computer Science, University of Nottingham, Nottingham, UK
| | - Sarah Forster
- NIHR Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Philip Quinlan
- Digital Research Service, University of Nottingham, Nottingham, UK
| | | | - Tricia M McKeever
- NIHR Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Dominick Shaw
- Department of Respiratory Medicine, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB, UK.,NIHR Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
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16
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Plummer NR, Fogarty A, Shaw D, Card T, West J, Crooks C. Silent hypoxia is not an identifiable characteristic in patients with COVID-19 infection. Respir Med 2022; 197:106858. [PMID: 35490510 PMCID: PMC9047547 DOI: 10.1016/j.rmed.2022.106858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/08/2022] [Accepted: 04/20/2022] [Indexed: 11/26/2022]
Abstract
Background Methods Results Conclusions
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17
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Crozier I, Haqqani H, Kotschet E, Shaw D, Prabhu A, Roubos J, Alison J, Melton I, Denman R, Lin T, Almeida A, Thompson A, Lande J, Liang S, O’donnell D. Three-year chronic follow-up from the pilot study of a substernal extravascular implantable cardioverter defibrillator. Europace 2022. [DOI: 10.1093/europace/euac053.467] [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: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Medtronic
Background
The investigational Extravascular Implantable Cardioverter-Defibrillator (EV ICD) uses a substernal lead and delivers defibrillation and pacing therapies, including antitachycardia pacing (ATP).
Objective
To characterize EV ICD system performance through 3 years.
Methods
The prospective, first-in-human EV ICD Pilot study was conducted at 4 sites in Australia and New Zealand. ICD-indicated patients were enrolled July-December of 2018. Defibrillation testing was conducted for all patients at implant, and chronically per physician discretion. Electrical testing was conducted at pre-hospital discharge, 2 weeks, 4-6 weeks and 3 months post-implant, and every 6 months thereafter. Posture effects on pacing and sensing were evaluated through 3 months.
Results
Of 26 patients enrolled, 21 underwent the EV ICD implant procedure. There were no intraprocedural complications. After successful implantation and testing, 17 of 21 patients entered chronic follow-up. 14 patients continue follow up, representing 523 patient-months. Eight elective chronic defibrillation tests converted 7 of 7 patients with ≤ 40 J (maximum energy). Five episodes of spontaneous ventricular tachycardia (VT) were detected in 1 patient and either self-terminated or successfully defibrillated with appropriate shock.
Over the total course of follow-up, 3 patients received an inappropriate shock due to; lead tip displacement with subsequent P-wave oversensing; Electromagnetic interference (EMI) in a ungrounded hot-tub; and EMI while doing plumbing work on unearthed electrical pipes, resulting in an annualized inappropriate shock rate of 6.9%.
Pacing capture thresholds remained stable across time (5.1 ± 2.0 V at implant and 5.5 ± 2.7 V at 3 years); similarly, R-wave amplitudes were stable across time (3.4 ±2.0 mV at implant and 4.2 ± 2.7 mV at 3 years). Pacing thresholds tended to be lowest with the patient lying on the right side and pacing threshold often increased relative to supine position for left-side, prone or bending postures. R-wave amplitude tended to be greater when bending forward.
There were 10 system or procedure-related adverse events in 8 patients through 3 years, including 3 elective system removals for: a single inappropriate shock (1), chronic defibrillation testing showing no safety margin in a patient with arrhythmogenic right ventricular dysplasia (1), intolerance to ATP (1 - high pacing threshold and frequent VT). Other than the lead tip displacement within the first 3 months, no additional clinically significant lead displacements have been observed through 3 years.
Conclusion
The EV ICD is a novel platform for delivering high-voltage therapy. There were no procedure and system related complications observed after the first year post-implant. Lead position and chronic system performance have generally remained stable through 3 years with a low rate of adverse events.
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Affiliation(s)
- I Crozier
- Christchurch Hospital, cardiology, Christchurch, New Zealand
| | - H Haqqani
- The Prince Charles Hospital, Department of Cardiology, Brisbane, Australia
| | - E Kotschet
- Monash Medical Center, Department of Cardiac Rhythm Services, Clayton, Australia
| | - D Shaw
- Christchurch Hospital, cardiology, Christchurch, New Zealand
| | - A Prabhu
- The Prince Charles Hospital, Department of Cardiology, Brisbane, Australia
| | - J Roubos
- Austin Health, Department of Cardiology, Heidelberg, Australia
| | - J Alison
- Monash Medical Center, Department of Cardiac Rhythm Services, Clayton, Australia
| | - I Melton
- Christchurch Hospital, cardiology, Christchurch, New Zealand
| | - R Denman
- The Prince Charles Hospital, Department of Cardiology, Brisbane, Australia
| | - T Lin
- Austin Health, Department of Cardiology, Heidelberg, Australia
| | - A Almeida
- Monash Medical Center, Department of Cardiac Rhythm Services, Clayton, Australia
| | - A Thompson
- Medtronic, Inc., Minneapolis, United States of America
| | - J Lande
- Medtronic, Inc., Minneapolis, United States of America
| | - S Liang
- Medtronic, Inc., Minneapolis, United States of America
| | - D O’donnell
- Austin Health, Department of Cardiology, Heidelberg, Australia
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18
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Crooks CJ, West J, Morling JR, Simmonds M, Juurlink I, Briggs S, Cruickshank S, Hammond-Pears S, Shaw D, Card TR, Fogarty A. Age modifies both the maximal temperature and inflammatory response in patients with SARS-CoV-2 infection. Clin Med (Lond) 2022; 22:192-196. [PMID: 38589079 PMCID: PMC9135072 DOI: 10.7861/clinmed.2021-0603] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the maximal response of the temperature and inflammatory response to SARS-CoV-2 infection and how these are modified by age. METHODS Participants were patients admitted to hospital with SARS-CoV-2 infection. For each participant, the maximal temperature and serum C-reactive protein (CRP) were identified and stratified by age. In a secondary analysis, these were compared in patients treated before and after dexamethasone. RESULTS Mean maximal temperature varied by age (p<0.001; ANOVA) with the highest mean maximal temperature of 37.3°C observed in patients aged 30-49 years and decreasing maximal mean temperatures in the older age groups, with the lowest measure of 36.8°C observed in individuals aged 90-99 years. The mean maximal serum CRP also varied across age groups (p<0.001; ANOVA) and increased with age across all age categories from 34.5 mg/dL (95% confidence interval (CI) 22.0-47.0) for individuals aged 20-29 years to 77.6 mg/dL (95% CI 72.0-83.2) in those aged 80-89 years. After dexamethasone became standard treatment for COVID-19 pneumonia, mean maximal CRP decreased by 17 mg/dL (95% CI -22 to -11). CONCLUSION Age modifies both maximal temperature and systemic inflammatory response in patients with SARS-CoV-2 infection.
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Affiliation(s)
- Colin J Crooks
- Nottingham Digestive Diseases Centre, Nottingham, UK, NIHR Nottingham Biomedical Research Centre, Nottingham, UK and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joe West
- University of Nottingham, Nottingham, UK, NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and East Midlands Academic Health Science Network, Nottingham, UK
| | - Joanne R Morling
- University of Nottingham, Nottingham, UK, NIHR Nottingham Biomedical Research Centre, Nottingham, UK and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark Simmonds
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Irene Juurlink
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steve Briggs
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Susan Hammond-Pears
- Nottingham University Hospitals NHS Trust, Nottingham, UK and East Midlands Academic Health Science Network, Nottingham, UK
| | - Dominick Shaw
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Timothy R Card
- University of Nottingham, Nottingham, UK, NIHR Nottingham Biomedical Research Centre, Nottingham, UK and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Fogarty
- University of Nottingham, Nottingham, UK, NIHR Nottingham Biomedical Research Centre, Nottingham, UK and Nottingham University Hospitals NHS Trust, Nottingham, UK.
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Crooks CJ, West J, Morling JR, Simmonds M, Juurlink I, Briggs S, Cruickshank S, Hammond-Pears S, Shaw D, Card TR, Fogarty AW. Pulse oximeter measurements vary across ethnic groups: an observational study in patients with COVID-19. Eur Respir J 2022; 59:13993003.03246-2021. [PMID: 35086839 PMCID: PMC8796692 DOI: 10.1183/13993003.03246-2021] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 01/02/2022] [Indexed: 11/22/2022]
Abstract
The pulse oximeter provides regular non-invasive measurements of blood oxygenation and is used in a wide range of clinical settings [1]. The light wave transmission that this technology uses is modified by skin pigmentation and thus may vary by skin colour. A recent study of paired measures of oxygen saturation from pulse oximetry and arterial blood gas reported differing outputs in patients with black skin compared to patients with white skin that has the potential to adversely impact on patient care [2]. Be aware that pulse oximeters overestimate oxygen saturation measurements in patients with hypoxaemia, and that this error is larger in individuals from black and Asian ethnic groupshttps://bit.ly/3fCeJP7
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Affiliation(s)
- Colin J. Crooks
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK,NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joe West
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham University Hospitals NHS Trust, Nottingham, UK,Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK,East Midlands Academic Health Science Network, University of Nottingham, Nottingham, UK
| | - Joanne R. Morling
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham University Hospitals NHS Trust, Nottingham, UK,Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Mark Simmonds
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Irene Juurlink
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steve Briggs
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Susan Hammond-Pears
- Nottingham University Hospitals NHS Trust, Nottingham, UK,East Midlands Academic Health Science Network, University of Nottingham, Nottingham, UK
| | - Dominick Shaw
- Nottingham University Hospitals NHS Trust, Nottingham, UK,Division of Respiratory Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Timothy R. Card
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham University Hospitals NHS Trust, Nottingham, UK,Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Andrew W. Fogarty
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham University Hospitals NHS Trust, Nottingham, UK,Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK,Andrew W. Fogarty ()
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20
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Llewelyn MJ, Grozeva D, Howard P, Euden J, Gerver SM, Hope R, Heginbothom M, Powell N, Richman C, Shaw D, Thomas-Jones E, West RM, Carrol ED, Pallmann P, Sandoe JAT. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1189-1196. [PMID: 35137110 PMCID: PMC9383456 DOI: 10.1093/jac/dkac017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/06/2022] [Indexed: 01/08/2023] Open
Abstract
Background Blood biomarkers have the potential to help identify COVID-19 patients with bacterial coinfection in whom antibiotics are indicated. During the COVID-19 pandemic, procalcitonin testing was widely introduced at hospitals in the UK to guide antibiotic prescribing. We have determined the impact of this on hospital-level antibiotic consumption. Methods We conducted a retrospective, controlled interrupted time series analysis of organization-level data describing antibiotic dispensing, hospital activity and procalcitonin testing for acute hospitals/hospital trusts in England and Wales during the first wave of COVID-19 (24 February to 5 July 2020). Results In the main analysis of 105 hospitals in England, introduction of procalcitonin testing in emergency departments/acute medical admission units was associated with a statistically significant decrease in total antibiotic use of −1.08 (95% CI: −1.81 to −0.36) DDDs of antibiotic per admission per week per trust. This effect was then lost at a rate of 0.05 (95% CI: 0.02–0.08) DDDs per admission per week. Similar results were found specifically for first-line antibiotics for community-acquired pneumonia and for COVID-19 admissions rather than all admissions. Introduction of procalcitonin in the ICU setting was not associated with any significant change in antibiotic use. Conclusions At hospitals where procalcitonin testing was introduced in emergency departments/acute medical units this was associated with an initial, but unsustained, reduction in antibiotic use. Further research should establish the patient-level impact of procalcitonin testing in this population and understand its potential for clinical effectiveness.
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Affiliation(s)
- Martin J. Llewelyn
- Global Health and Infectious Diseases, Brighton and Sussex Medical School, University of Sussex, Brighton, BN1 9PS, UK
- Department of Microbiology and Infection, University Hospitals Sussex NHS Foundation Trust, Brighton, BN2 5BE, UK
- Corresponding author. E-mail:
| | - Detelina Grozeva
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - Philip Howard
- School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK
- Pharmacy Department, Leeds Teaching Hospitals, Leeds, LS1 3EX, UK
| | - Joanne Euden
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - Sarah M. Gerver
- Division of Healthcare Associated Infections and Antimicrobial Resistance, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Russell Hope
- Division of Healthcare Associated Infections and Antimicrobial Resistance, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Margaret Heginbothom
- Healthcare Associated Infection, Antimicrobial Resistance and Prescribing Programme, Public Health Wales, 2 Capital Quarter, Tyndall St, Cardiff, CF10 4BZ, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro, TR1 3LJ, UK
| | - Colin Richman
- Rx-Info Ltd, Exeter Science Park, 6 Babbage Way, Exeter, EX5 2FN, UK
| | - Dominick Shaw
- NIHR Respiratory Biomedical Research Centre, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - Robert M. West
- University of Leeds, Worsley Building, Clarendon Way, Leeds, LS2 9LU, UK
| | - Enitan D. Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK
| | - Philip Pallmann
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - Jonathan A. T. Sandoe
- Department of Microbiology, The Old Medical School, The General Infirmary at Leeds, Leeds, LS1 3EX, UK
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21
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Bhaker S, Portelli MA, Rakkar K, Shaw D, Johnson S, Brightling C, Sayers I. Human bronchial epithelial cells from patients with asthma have an altered gene expression profile. ERJ Open Res 2021; 8:00625-2021. [PMID: 35198626 PMCID: PMC8859501 DOI: 10.1183/23120541.00625-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/10/2021] [Indexed: 11/22/2022] Open
Abstract
Asthma is a multifactorial disease presenting with wheeze and shortness of breath, and is known to be exacerbated by triggers such as pollen, house dust mites and viral infection. In the lung, the bronchial epithelium is recognised as a central driver of airway structural changes, including epithelial goblet cell hyperplasia and metaplasia, which are features of asthma. Bronchial epithelial cells (BECs) isolated from patients with asthma and cultured in vitro have altered barrier properties [1], elevated expression of remodelling factors [2] and defective repair [3]. Interestingly, genome-wide association studies (GWAS) of asthma have implicated a number of genes that are known to be expressed and functional in the airway epithelium, including IL33, IL1RL1, TSLP and MUC5AC [4]. To identify the molecular mechanisms underlying altered BECs phenotype in asthma patients, several studies have completed transcriptomic analyses using bronchial brush samples. Two recent meta-analyses [5, 6] suggested that alterations in chemical stimulus, extracellular region, pathways in cancer and arachidonic acid metabolism were features of the bronchial epithelium in the lungs of patients with asthma, and included 78 up- and 75 down-regulated genes [5]. While useful, a key question is how much the airway environment of a patient is driving this differential gene expression profile (GEP) and how much is intrinsic to the BECs themselves? To answer this question, we completed transcriptomic analyses of BECs cultured two-dimensionally through multiple passages in the laboratory that had originally been isolated from control subjects without disease or patients with asthma. An attrition rate (for successful culture) of 54% and 42% was observed in the asthma and control populations respectively. Gene changes observed in asthma bronchial epithelial cells are maintained following repeated culture, presenting with an exaggerated response to viral infection and immune responses as well as having differences in the rate of cell division and replicationhttps://bit.ly/3Cq2xKf
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Frappaz D, Dhall G, Murray MJ, Goldman S, Faure Conter C, Allen J, Kortmann R, Haas-Kogen D, Morana G, Finlay J, Nicholson JC, Bartels U, Souweidane M, Schöenberger S, Vasiljevic A, Robertson P, Albanese A, Alapetite C, Czech T, Lau CC, Wen P, Schiff D, Shaw D, Calaminus G, Bouffet E. Intracranial germ cell tumors in Adolescents and Young Adults: European and North American consensus review, current management and future development. Neuro Oncol 2021; 24:516-527. [PMID: 34724065 PMCID: PMC8972311 DOI: 10.1093/neuonc/noab252] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [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: 11/14/2022] Open
Abstract
The incidence of intracranial germ cell tumors (iGCT) is much lower in European and North American (E&NA) than in Asian population. However, E&NA cooperative groups have simultaneously developed with success treatment strategies with specific attention paid to long-term sequelae. Neurological sequelae may be reduced by establishing a diagnosis with an endoscopic biopsy and/or cerebrospinal fluid (CSF) and/or serum analysis, deferring the need to perform a radical surgery. Depending on markers and/or histological characteristics, patients are treated as either germinoma or non-germinomatous germ cell tumors (NGGCT). Metastatic disease is defined by a positive CSF cytology and/or distant drops in craniospinal MRI. The combination of surgery and/or chemotherapy and radiation therapy is tailored according to grouping and staging. With more than 90% 5-year event-free survival (EFS), localized germinomas can be managed without aggressive surgery, and benefit from chemotherapy followed by whole ventricular irradiation with local boost. Bifocal germinomas are treated as non-metastatic entities. Metastatic germinomas may be cured with craniospinal irradiation. With a 5-year EFS over 70%, NGGCT benefit from chemotherapy followed by delayed surgery in case of residual disease, and some form of radiotherapy. Future strategies will aim at decreasing long-term side effects while preserving high cure rates.
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Affiliation(s)
- D Frappaz
- Institut d'Hématologie Oncologie Pédiatrique, Lyon, France
| | - G Dhall
- University of Alabama at Birmingham (UAB), Birmingham, USA
| | - M J Murray
- Department of Pathology, University of Cambridge, Cambridge, UK.,Department of Paediatric Haematology and Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Goldman
- Phoenix Children's Hospital University of Arizona, USA
| | - C Faure Conter
- Institut d'Hématologie Oncologie Pédiatrique, Lyon, France
| | - J Allen
- NYU Grossman School, New York, USA
| | - R Kortmann
- University of Leipzig Medical Center; Leipzig, Germany
| | | | | | - J Finlay
- Nationwide Children's Hospital, Colombus, USA
| | - J C Nicholson
- Department of Paediatric Haematology and Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ute Bartels
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - M Souweidane
- Memorial Sloan Kettering Cancer Center, New York, USA
| | - S Schöenberger
- Department of Pediatric Hematology and Oncology, University Hospital Essen, Essen, Germany
| | - A Vasiljevic
- Centre de Pathologie et Neuropathologie Est, Hospices Civils de Lyon, France
| | | | | | | | - T Czech
- Medical University of Vienna, Austria
| | - C C Lau
- Connecticut Children's Medical Center, USA
| | - P Wen
- University of Leipzig Medical Center; Leipzig, Germany
| | - D Schiff
- University of Virginia School of Medicine, Charlottesville, USA
| | - D Shaw
- Seattle Children's Hospital and University of Washington, Seattle USA
| | | | - E Bouffet
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Watts A, Watkinson W, Shaw D. 89 Do Corticosteroid and Local Anaesthetic Hip Injections Administered Proximal or Distal to The Zona Orbicularis Have an Effect on Patient Satisfaction? Br J Surg 2021. [DOI: 10.1093/bjs/znab259.967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aim
Pubofemoral and ischiofemoral ligaments blend to make zona orbicularis. Zonaorbicularis has been suggested to force fluid from peripheral compartment to central compartment in unidirectional flow. This study aims to assess whether injection of corticosteroid with local anaesthetic injected either proximal or distal to the zona orbicularis has effect on patient satisfaction.
Method
This retrospective study investigated consecutive patients undergoing ultrasound guided hip injections at a single centre in the UK between November 2018 and March 2019. Patients were identified using IMPAX© picture archiving and communications system. Radiographs were assessed to see if radiopaque dye and therefore corticosteroid and local anaesthetic had been injected proximal or distal to the zona orbicularis. Clinic letters were accessed on the electronic patient record and we recorded whether patients had pain relief at 24 hours and 2 weeks following hip injection.
Results
133 Patients were identified during the study period, of which 40 were included. At 24 hours post-injection 72% of patients were satisfied and 28% were unsatisfied, for which there was 76% and 70% satisfaction for proximal and distal injections respectively (p = 0.63). At 2 weeks post-injection 45% of patients were satisfied and 55% of patients unsatisfied, for which there was 47% and 44% satisfaction for proximal and distal injections respectively (p = 0.9).
Conclusions
Overall patient satisfaction is high following hip corticosteroid and local anaesthetic injection. No difference was found between injections proximal and distal to the zona orbicularis. Further research is needed to quantify the association between proximal and distal injections.
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Affiliation(s)
- A Watts
- Bradford Royal Infirmary, Bradford, United Kingdom
| | - W Watkinson
- Bradford Royal Infirmary, Bradford, United Kingdom
| | - D Shaw
- Bradford Royal Infirmary, Bradford, United Kingdom
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Chalitsios C, Shaw D, Mckeever T. Assesing the impact of corticosteroids on bone health in people with asthma: a systematic review and meta-analysis. Epidemiology 2021. [DOI: 10.1183/13993003.congress-2021.oa1326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gardiner D, McGee A, Shaw D. Two fundamental ethical and legal rules for deceased organ donation. BJA Educ 2021; 21:292-299. [PMID: 34306730 DOI: 10.1016/j.bjae.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- D Gardiner
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A McGee
- Queensland University of Technology, Brisbane, QLD, Australia
| | - D Shaw
- Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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Sutherland L, Shaw K, Parrish C, Singleton N, McKeever TM, Stewart I, Shaw D, Martin MJ, Harrison T. A low exhaled nitric oxide level excludes a short-term benefit from inhaled corticosteroids in suspected asthma: A randomized placebo-controlled trial. Respirology 2021; 26:666-672. [PMID: 33939245 DOI: 10.1111/resp.14055] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 01/29/2021] [Accepted: 02/23/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVE Fractional exhaled nitric oxide (FeNO) is a non-invasive biomarker that reflects IL-4/IL-13 production and therefore represents T2 allergic inflammation. FeNO has previously been used to guide inhaled corticosteroid (ICS) treatment in asthma. The purpose of this study was to determine if a low FeNO (≤27 ppb) could be used to reliably identify patients with symptoms suggestive of asthma who would not benefit from initiating treatment with an ICS. METHODS A total of 180 steroid-naïve adults with healthcare professional suspected asthma and an FeNO of ≤27 ppb were randomized to receive either 400 mcg of budesonide or placebo daily for 3 months. The primary outcome was the difference in the Asthma Control Questionnaire 7 (ACQ7) between treatment groups and the study was powered to determine equivalence. Secondary outcomes were the difference in FEV1 , Medical Research Council and Leicester Cough Questionnaire scores. RESULTS One hundred and thirty-four patients (68 budesonide and 66 placebo) completed the study and were included in the analysis. The between-group mean difference in ACQ7 from baseline to the end of the study was -0.25 and the 95% CI around this difference was -0.004 to 0.495 confirming equivalence (p < 0.05). Differences in forced expiratory volume over 1 s and other secondary outcomes were also small and clinically unimportant. CONCLUSION The results of this study suggest that steroid-naïve patients with symptoms suggestive of asthma and an FeNO ≤ 27 ppb are unlikely to benefit from initiating treatment with an ICS over 3 months. However, further research is recommended to confirm these findings before withholding ICS treatment.
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Affiliation(s)
- Lissa Sutherland
- School of Life Sciences, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Karen Shaw
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Clair Parrish
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Nicola Singleton
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Tricia M McKeever
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Iain Stewart
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Dominick Shaw
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Matthew J Martin
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
| | - Tim Harrison
- School of Medicine, NIHR BRC University of Nottingham, University of Nottingham, Nottingham City Hospital, Nottingham, UK
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Sellers R, Harold GT, Smith AF, Neiderhiser JM, Reiss D, Shaw D, Natsuaki MN, Thapar A, Leve LD. Disentangling nature from nurture in examining the interplay between parent-child relationships, ADHD, and early academic attainment. Psychol Med 2021; 51:645-652. [PMID: 31839017 PMCID: PMC7295681 DOI: 10.1017/s0033291719003593] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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] [Indexed: 01/05/2023]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is highly heritable and is associated with lower educational attainment. ADHD is linked to family adversity, including hostile parenting. Questions remain regarding the role of genetic and environmental factors underlying processes through which ADHD symptoms develop and influence academic attainment. METHOD This study employed a parent-offspring adoption design (N = 345) to examine the interplay between genetic susceptibility to child attention problems (birth mother ADHD symptoms) and adoptive parent (mother and father) hostility on child lower academic outcomes, via child ADHD symptoms. Questionnaires assessed birth mother ADHD symptoms, adoptive parent (mother and father) hostility to child, early child impulsivity/activation, and child ADHD symptoms. The Woodcock-Johnson test was used to examine child reading and math aptitude. RESULTS Building on a previous study (Harold et al., 2013, Journal of Child Psychology and Psychiatry, 54(10), 1038-1046), heritable influences were found: birth mother ADHD symptoms predicted child impulsivity/activation. In turn, child impulsivity/activation (4.5 years) evoked maternal and paternal hostility, which was associated with children's ADHD continuity (6 years). Both maternal and paternal hostility (4.5 years) contributed to impairments in math but not reading (7 years), via impacts on ADHD symptoms (6 years). CONCLUSION Findings highlight the importance of early child behavior dysregulation evoking parent hostility in both mothers and fathers, with maternal and paternal hostility contributing to the continuation of ADHD symptoms and lower levels of later math ability. Early interventions may be important for the promotion of child math skills in those with ADHD symptoms, especially where children have high levels of early behavior dysregulation.
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Affiliation(s)
- R Sellers
- School of Psychology, Andrew and Virginia Rudd Centre for Adoption Research and Practice, University of Sussex, Brighton, UK
- Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - G T Harold
- School of Psychology, Andrew and Virginia Rudd Centre for Adoption Research and Practice, University of Sussex, Brighton, UK
- Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
- School of Psychology, Trinity College Dublin, The University of Dublin, Ireland
| | - A F Smith
- School of Psychology, Andrew and Virginia Rudd Centre for Adoption Research and Practice, University of Sussex, Brighton, UK
| | - J M Neiderhiser
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - D Reiss
- Yale Child Study Center, New Haven, CT, USA
| | - D Shaw
- University of Pittsburgh, Pittsburgh, PA, USA
| | | | - A Thapar
- Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - L D Leve
- Prevention Science Institute, University of Oregon, Eugene, ORUSA
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Wilson SJ, Ward JA, Pickett HM, Baldi S, Sousa AR, Sterk PJ, Chung KF, Djukanovic R, Dahlen B, Billing B, Shaw D, Krug N, Sandstrӧm T, Brightling C, Howarth PH. Airway Elastin is increased in severe asthma and relates to proximal wall area: histological and computed tomography findings from the U-BIOPRED severe asthma study. Clin Exp Allergy 2021; 51:296-304. [PMID: 33342006 DOI: 10.1111/cea.13813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/08/2020] [Accepted: 12/15/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Airway remodelling, which may include goblet cell hyperplasia / hypertrophy, changes in epithelial integrity, accumulation of extracellular matrix components, smooth muscle hypertrophy and thickening of the lamina reticularis, is a feature of severe asthma and contributes to the clinical phenotype. OBJECTIVE Within the U-BIOPRED severe asthma study, we have assessed histological elements of airway remodelling and their relationship to computed tomography (CT) measures of proximal airway dimensions. METHODS Bronchial biopsies were collected from two severe asthma groups, one non-smoker (SAn, n = 28) and one current/ex-smoker (SAs/ex, n = 13), and a mild-moderate asthma group (MMA, n = 28) classified and treated according to GINA guidelines, plus a healthy control group (HC, n = 33). Movat's pentachrome technique was used to identify mucin, elastin and total collagen in these biopsies. The number of goblet cells (mucin+) was counted as a percentage of the total number of epithelial cells and the percentage mucin epithelial area measured. The percentage area of elastic fibres and total collagen within the submucosa was also measured, and the morphology of the elastic fibres classified. Participants in the asthma groups also had a CT scan to assess large airway morphometry. RESULTS The submucosal tissue elastin percentage was higher in both severe asthma groups (16.1% SAn, 18.9% SAs/ex) compared with the HC (9.7%) but did not differ between asthma groups. There was a positive relationship between elastin and airway wall area measured by CT (n = 18-20, rho=0.544, p = 0.024), which also related to an increase in elastic fibres with a thickened lamellar morphological appearance. Mucin epithelial area and total collagen were not different between the four groups. Due to small numbers of suitable CT scans, it was not feasible to compare airway morphometry between the asthma groups. CONCLUSION These findings identify a link between extent of elastin deposition and airway wall thickening in severe asthma.
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Affiliation(s)
- Susan J Wilson
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jonathan A Ward
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Helen M Pickett
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Simonetta Baldi
- Department of Respiratory Science, University of Leicester, Leicester, UK
| | - Ana R Sousa
- Respiratory Therapy Unit, GlaxoSmithKline, Stevenage, UK
| | - Peter J Sterk
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kian Fan Chung
- National Heart & Lung Institute, Imperial College London, London, UK
| | | | - Barbro Dahlen
- Department of Respiratory Medicine and Allergy, The Centre for Allergy Research, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bo Billing
- Department of Respiratory Medicine and Allergy, The Centre for Allergy Research, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Dominick Shaw
- Nottingham Respiratory Research, University of Nottingham, Nottingham, UK
| | - Norbert Krug
- Fraunhofer Institute of Toxicology & Experimental Medicine, Hannover, Germany
| | - Thomas Sandstrӧm
- Department of Respiratory Medicine, Umea University, Stockholm, Sweden
| | | | - Peter H Howarth
- Faculty of Medicine, University of Southampton, Southampton, UK
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Kheslat H, Bowers P, Shaw D. P53 The Re-birth of the Vineberg Procedure? A Historical Perspective and a Case Study of Successful Internal Mammary Artery Implantation in a Stent-Obliterated Left Anterior Descending Artery. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.03.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dean E, Kheslat H, Crozier I, Shaw D. P50 Autogenic Cardiac Injury as a Cause of Valvular Dysfunction. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.03.253] [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: 12/01/2022]
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Affiliation(s)
- D Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
- Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - T S J Crabtree
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - P Hammond
- Harrogate and District Foundation Trust, Harrogate, UK
| | | | - E G Wilmot
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
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Shaw D, Faino A, Statland J, Eichinger K, Tapscott S, Tawil R, Friedman S, Wang L. FSHD / OPMD / MYOTONIC DYSTROPHY. Neuromuscul Disord 2020. [DOI: 10.1016/j.nmd.2020.08.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Birk R, Shaw D, Kennedy C, Higashi Y, Patel R, Gupta A, Au-Yong I. Low Detection Rate of Pulmonary Embolism in Patients Presenting to the Emergency Department With Suspected Coronavirus Disease 2019 (COVID-19): A Single-Centre UK Study. Curr Probl Diagn Radiol 2020; 50:656-661. [PMID: 33036814 PMCID: PMC7510589 DOI: 10.1067/j.cpradiol.2020.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/04/2020] [Accepted: 09/15/2020] [Indexed: 01/08/2023]
Abstract
Purpose Critically ill patients with coronavirus disease 2019 (COVID-19) are at increased risk of thrombosis. There are limited data on PE rates in COVID-19 patients at presentation to the emergency department (ED). In this study, we evaluated the detection rates of PE in patients presenting to the ED with suspected and proven COVID-19. Methods A single-centre retrospective study was undertaken of 285 consecutive patients undergoing CT pulmonary angiogram (CTPA) in the Emergency Department at Nottingham University Hospitals NHS Trust in the United Kingdom between 25 March and 30 April 2020. At our institution, CTPA is performed in all patients undergoing CT for triage. The study group consisted of patients considered COVID-19 positive based on polymerase chain reaction (PCR) results and CTPA findings. The detection rate of PE in COVID-19 patients was compared to patients undergoing CTPA for suspected PE only and for suspected COVID-19 with no COVID CT findings and negative PCR (control group 1); and CTPAs prior to the coronavirus pandemic (control group 2). Results One of 48 patients in the study group had a PE (2%) compared to 25/215 (12%) in control group 1 and 10/50 (20%) in control group 2. Prevalence of PE in the study group was lower than in control group 1 (P = 0.058) and compared to control group 2 (P = 0.005). Eleven patients undergoing CTPA had negative PCR but positive CT for COVID-19. Conclusion Detection rate of pulmonary embolus is low in patients with COVID-19 undergoing CTPA on a triage pathway.
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Affiliation(s)
- Rubinder Birk
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Dominick Shaw
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, United Kingdom
| | - Cheika Kennedy
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Yutaro Higashi
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Roma Patel
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Ayushman Gupta
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, United Kingdom
| | - Iain Au-Yong
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
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Affiliation(s)
- Andrew Fogarty
- Nottingham NIHR Respiratory Biomedical Research Centre, University of Nottingham, Nottingham NG5 1PB, UK
| | - Amelia Joseph
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dominick Shaw
- Nottingham NIHR Respiratory Biomedical Research Centre, University of Nottingham, Nottingham NG5 1PB, UK.
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Portelli M, Londei M, Shaw D, Johnson S, Brightling C, Sayers I. Rhinovirus & IL33 driven HBEC gene signatures are disease & IL1RL1 polymorphism dependent. Genes Environ 2020. [DOI: 10.1183/13993003.congress-2020.1119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Wang K, Verbakel JY, Oke J, Fleming-Nouri A, Harada N, Atsuta R, Fujisawa T, Kawayama T, Inoue H, Lazarus S, Szefler S, Martinez FD, Shaw D, Pavord ID, Thomas M. Using fractional exhaled nitric oxide to guide step-down treatment decisions in asthma: practical considerations. Eur Respir J 2020; 56:56/2/2002809. [PMID: 32820024 DOI: 10.1183/13993003.02809-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Kay Wang
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jan Y Verbakel
- KU Leuven, Dept of Public Health and Primary Care, Leuven, Belgium
| | - Jason Oke
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Norihiro Harada
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Ryo Atsuta
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Tomoyuki Fujisawa
- Second Division Dept of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Kurume University School of Medicine, Kurume, Japan
| | - Hiromasa Inoue
- Dept of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Stephen Lazarus
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
| | - Stanley Szefler
- Children's Hospital Colorado, The Breathing Institute, Dept of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Fernando D Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Dominick Shaw
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Ian D Pavord
- Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Mike Thomas
- Primary Care, Population Sciences and Medical Education (PPM), University of Southampton, Southampton, UK
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Wang K, Verbakel JY, Oke J, Fleming-Nouri A, Brewin J, Roberts N, Harada N, Atsuta R, Takahashi K, Mori K, Fujisawa T, Shirai T, Kawayama T, Inoue H, Lazarus S, Szefler S, Martinez F, Shaw D, Pavord ID, Thomas M. Using fractional exhaled nitric oxide to guide step-down treatment decisions in patients with asthma: a systematic review and individual patient data meta-analysis. Eur Respir J 2020; 55:13993003.02150-2019. [PMID: 32139458 DOI: 10.1183/13993003.02150-2019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND High exhaled nitric oxide fraction (F ENO) levels are associated with greater risk of asthma exacerbation. However, it is not clear how F ENO can be used to guide safe reductions in inhaled corticosteroid (ICS) doses in asthma patients. This study assesses the ability of F ENO to guide ICS reductions. METHODS Systematic searching of electronic databases identified prospective observational studies and randomised controlled trials which recruited participants with mild-to-moderate asthma aged ≥12 years and measured F ENO before reducing ICS. We performed multilevel mixed-effects logistic regression in relation to acute exacerbations and estimated each participant's exacerbation risk using our logistic regression model. RESULTS We included data from seven out of eight eligible studies, representing 384 participants. ICS doses were halved in four studies and withdrawn in three studies. A baseline F ENO measurement of ≥50 ppb was associated with increased risk of exacerbations (crude OR 3.14, 95% CI 1.41-7.00, p=0.005; adjusted OR 3.08, 95% CI 1.36-6.98, p=0.007) and corresponded to an estimated exacerbation risk cut-off of 15%. Reducing ICS when estimated exacerbation risk was <15% versus <10% would result in fewer patients remaining on the same ICS dose (40 (10.4%) out of 384 versus 141 (36.7%) out of 384), but similar proportions of patients avoiding exacerbations (222 (91.4%) out of 243, 95% CI 87.1-94.6% versus 311 (90.4%) out of 344, 95% CI 86.8-93.3%). CONCLUSION In patients with mild-to-moderate asthma, gradual ICS reduction when F ENO is <50 ppb may help decrease ICS use without increasing exacerbations. Future research should aim to validate these findings in larger populations.
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Affiliation(s)
- Kay Wang
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jan Y Verbakel
- KU Leuven, Dept of Public Health and Primary Care, Leuven, Belgium
| | - Jason Oke
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Josh Brewin
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Norihiro Harada
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Ryo Atsuta
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Kazuhisa Takahashi
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Kazutaka Mori
- Second Division Dept of Internal Medicine, Hamamatsu University School of Medicine, Hammamatsu, Japan
| | - Tomoyuki Fujisawa
- Second Division Dept of Internal Medicine, Hamamatsu University School of Medicine, Hammamatsu, Japan
| | - Toshihiro Shirai
- Dept of Respiratory Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Kurume University School of Medicine, Kurume, Japan
| | - Hiromasa Inoue
- Dept of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Stephen Lazarus
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
| | - Stanley Szefler
- Children's Hospital Colorado, The Breathing Institute, Dept of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Fernando Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Dominick Shaw
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Ian D Pavord
- Oxford Respiratory NIHR BRC and Respiratory Medicine Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Mike Thomas
- Primary Care, Population Sciences and Medical Education (PPM), University of Southampton, Southampton, UK
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Young B, Fogarty AW, Skelly R, Shaw D, Sturrock N, Norwood M, Thurley P, Lewis S, Langley T, Cranwell J. Hospital doctors' attitudes to brief educational messages that aim to modify diagnostic test requests: a qualitative study. BMC Med Inform Decis Mak 2020; 20:80. [PMID: 32349739 PMCID: PMC7191798 DOI: 10.1186/s12911-020-1087-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Received: 12/20/2019] [Accepted: 03/31/2020] [Indexed: 11/25/2022] Open
Abstract
Background Avoidable use of diagnostic tests can both harm patients and increase the cost of healthcare. Nudge-type educational interventions have potential to modify clinician behaviour while respecting clinical autonomy and responsibility, but there is little evidence how this approach may be best used in a healthcare setting. This study aims to explore attitudes of hospital doctors to two nudge-type messages: one concerning potential future cancer risk after receiving a CT scan, another about the financial costs of blood tests. Methods We added two brief educational messages to diagnostic test results in a UK hospital for one year. One message on the associated long-term potential cancer risk from ionising radiation imaging to CT scan reports, and a second on the financial costs incurred to common blood test results. We conducted a qualitative study involving telephone interviews with doctors working at the hospital to identify themes explaining their response to the intervention. Results Twenty eight doctors were interviewed. Themes showed doctors found the intervention to be highly acceptable, as the group had a high awareness of the need to prevent harm and optimise use of finite resources, and most found the nudge-type approach to be inoffensive and harmless. However, the messages were not seen as personally relevant because doctors felt they were already relatively conservative in their use of tests. Cancer risk was important in decision-making but was not considered to represent new knowledge to doctors. Conversely, financial costs were considered to be novel information that was unimportant in decision-making. Defensive medicine was commonly cited as a barrier to individual behaviour change. The educational cancer risk message on CT scan reports increased doctors’ confidence to challenge decisions and explain risks to patients and there were some modifications in clinical practice prompted by the financial cost message. Conclusion The nudge-type approach to target avoidable use of tests was acceptable to hospital doctors but there were barriers to behaviour change. There was evidence doctors perceived this cheap and light-touch method can contribute to culture change and form a foundation for more comprehensive educational efforts to modify behaviour in a healthcare environment.
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Affiliation(s)
- Ben Young
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK.
| | - Andrew W Fogarty
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Rob Skelly
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Dominick Shaw
- NIHR Nottingham Biomedical Research Centre, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Nigel Sturrock
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Mark Norwood
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Peter Thurley
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Tessa Langley
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Jo Cranwell
- Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK
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Portelli MA, Dijk FN, Ketelaar ME, Shrine N, Hankinson J, Bhaker S, Grotenboer NS, Obeidat M, Henry AP, Billington CK, Shaw D, Johnson SR, Pogson ZE, Fogarty A, McKeever TM, Nickle DC, Bossé Y, van den Berge M, Faiz A, Brouwer S, Vonk JM, de Vos P, Brandsma CA, Vermeulen CJ, Singapuri A, Heaney LG, Mansur AH, Chaudhuri R, Thomson NC, Holloway JW, Lockett GA, Howarth PH, Niven R, Simpson A, Blakey JD, Tobin MD, Postma DS, Hall IP, Wain LV, Nawijn MC, Brightling CE, Koppelman GH, Sayers I. Phenotypic and functional translation of IL1RL1 locus polymorphisms in lung tissue and asthmatic airway epithelium. JCI Insight 2020; 5:132446. [PMID: 32324168 PMCID: PMC7205441 DOI: 10.1172/jci.insight.132446] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 03/12/2020] [Indexed: 12/22/2022] Open
Abstract
The IL1RL1 (ST2) gene locus is robustly associated with asthma; however, the contribution of single nucleotide polymorphisms (SNPs) in this locus to specific asthma subtypes and the functional mechanisms underlying these associations remain to be defined. We tested for association between IL1RL1 region SNPs and characteristics of asthma as defined by clinical and immunological measures and addressed functional effects of these genetic variants in lung tissue and airway epithelium. Utilizing 4 independent cohorts (Lifelines, Dutch Asthma GWAS [DAG], Genetics of Asthma Severity and Phenotypes [GASP], and Manchester Asthma and Allergy Study [MAAS]) and resequencing data, we identified 3 key signals associated with asthma features. Investigations in lung tissue and primary bronchial epithelial cells identified context-dependent relationships between the signals and IL1RL1 mRNA and soluble protein expression. This was also observed for asthma-associated IL1RL1 nonsynonymous coding TIR domain SNPs. Bronchial epithelial cell cultures from asthma patients, exposed to exacerbation-relevant stimulations, revealed modulatory effects for all 4 signals on IL1RL1 mRNA and/or protein expression, suggesting SNP-environment interactions. The IL1RL1 TIR signaling domain haplotype affected IL-33–driven NF-κB signaling, while not interfering with TLR signaling. In summary, we identify that IL1RL1 genetic signals potentially contribute to severe and eosinophilic phenotypes in asthma, as well as provide initial mechanistic insight, including genetic regulation of IL1RL1 isoform expression and receptor signaling.
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Affiliation(s)
- Michael A Portelli
- Division of Respiratory Medicine, NIHR, Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - F Nicole Dijk
- Department of Pediatric Pulmonology and Pediatric Allergology, and
| | - Maria E Ketelaar
- Division of Respiratory Medicine, NIHR, Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom.,Department of Pediatric Pulmonology and Pediatric Allergology, and.,Department of Pathology and Medical Biology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, Netherlands
| | - Nick Shrine
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Jenny Hankinson
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Sangita Bhaker
- Division of Respiratory Medicine, NIHR, Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Néomi S Grotenboer
- Department of Pediatric Pulmonology and Pediatric Allergology, and.,Department of Pathology and Medical Biology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, Netherlands
| | - Ma'en Obeidat
- The University of British Columbia Center for Heart Lung Innovation, St. Paul's Hospital Vancouver, Vancouver, British Columbia, Canada
| | - Amanda P Henry
- Division of Respiratory Medicine, NIHR, Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Charlotte K Billington
- Division of Respiratory Medicine, NIHR, Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Dominick Shaw
- Division of Respiratory Medicine, NIHR, Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Simon R Johnson
- Division of Respiratory Medicine, NIHR, Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Zara Ek Pogson
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Andrew Fogarty
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
| | - David C Nickle
- Departments of Genetics and Pharmacogenomics, Merck Research Laboratories, Boston, Massachusetts, USA
| | - Yohan Bossé
- Institut universitaire de cardiologie et de pneumologie de Québec, Department of Molecular Medicine, Laval University, Québec, Canada
| | - Maarten van den Berge
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Department of Pulmonary Diseases, and
| | - Alen Faiz
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Department of Pulmonary Diseases, and
| | - Sharon Brouwer
- Department of Pathology and Medical Biology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, Netherlands
| | - Judith M Vonk
- Department of Epidemiology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, Netherlands
| | - Paul de Vos
- Department of Pathology and Medical Biology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, Netherlands
| | - Corry-Anke Brandsma
- Department of Pathology and Medical Biology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, Netherlands
| | - Cornelis J Vermeulen
- Department of Pathology and Medical Biology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, Netherlands
| | - Amisha Singapuri
- Respiratory sciences, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Liam G Heaney
- Centre for Experimental Medicine, Queens University of Belfast, Belfast, United Kingdom
| | - Adel H Mansur
- Department of Respiratory Medicine, Birmingham Heartlands Hospital and University of Birmingham, Birmingham, United Kingdom
| | - Rekha Chaudhuri
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Neil C Thomson
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - John W Holloway
- Department of Human Development and.,Department of Health & Clinical and Experimental Sciences, Faculty of Medicine and NIH Research (NIHR), Southampton Biomedical Research Centre, University of Southampton, Southampton, United Kingdom
| | - Gabrielle A Lockett
- Department of Human Development and.,Department of Health & Clinical and Experimental Sciences, Faculty of Medicine and NIH Research (NIHR), Southampton Biomedical Research Centre, University of Southampton, Southampton, United Kingdom
| | - Peter H Howarth
- Department of Human Development and.,Department of Health & Clinical and Experimental Sciences, Faculty of Medicine and NIH Research (NIHR), Southampton Biomedical Research Centre, University of Southampton, Southampton, United Kingdom
| | - Robert Niven
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Angela Simpson
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - John D Blakey
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Martin D Tobin
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom.,NIHR, Leicester Respiratory Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Dirkje S Postma
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Department of Pulmonary Diseases, and
| | - Ian P Hall
- Division of Respiratory Medicine, NIHR, Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Louise V Wain
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom.,NIHR, Leicester Respiratory Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Martijn C Nawijn
- Department of Pathology and Medical Biology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, Netherlands
| | - Christopher E Brightling
- Respiratory sciences, University of Leicester, Glenfield Hospital, Leicester, United Kingdom.,NIHR, Leicester Respiratory Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | | | - Ian Sayers
- Division of Respiratory Medicine, NIHR, Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
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Kemna M, Shaw D, Ameduri R, Azeka E, Bradford T, Jorgensen N, Lin K, Menteer J, Moller T, Reardon L, Schumacher K, Shih R, Stendahl G, West S, Wisotzkey B, Zangwill S. Posterior Reversible Encephalopathy Syndrome (PRES) after Pediatric Heart Transplantation: A Multicenter Study. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.1270] [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: 10/24/2022] Open
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Bourdin A, Shaw D, Menzies-Gow A, FitzGerald JM, Bleecker ER, Busse WW, Ferguson GT, Brooks L, Barker P, Gil EG, Martin UJ. Two-year integrated steroid-sparing analysis and safety of benralizumab for severe asthma. J Asthma 2019; 58:514-522. [PMID: 31859541 DOI: 10.1080/02770903.2019.1705333] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Treatment with benralizumab significantly reduces exacerbations and improves lung function after 1 year and decreases oral corticosteroid (OCS) use after 28 weeks for patients with severe, uncontrolled eosinophilic asthma. We assessed whether these effects on OCS reduction are sustained for up to an additional year of treatment while maintaining an acceptable safety profile. METHODS Data on OCS maintenance dosage were collected for adult patients with baseline blood eosinophil counts ≥150 cells/μL treated with add-on benralizumab 30 mg (every 4 [Q4W] or 8 weeks [Q8W; first three doses Q4W]) from the 28-week ZONDA study and were integrated with results from the predefined 56-week adult completion phase of the BORA extension study. Efficacy and safety were summarized descriptively. RESULTS For patients receiving benralizumab Q8W, the median daily OCS dosage reduction of 75% from baseline to end of treatment achieved in ZONDA was sustained at the end of the BORA extension period (median 67% reduction from baseline). This was estimated to result in a median cumulative OCS dosage of 2.98 g over the 1.5-year period for patients receiving benralizumab Q8W compared with 5.74 g if these patients had remained on their baseline OCS dosages prior to benralizumab initiation. All adverse event rates were similar between the BORA extension and ZONDA periods, with no new or unexpected safety findings. CONCLUSION This benralizumab 1.5-year integrated analysis demonstrates that OCS reductions and safety were maintained with further follow up and supports long-term use of benralizumab for patients with severe, uncontrolled eosinophilic asthma.
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Affiliation(s)
- Arnaud Bourdin
- Department of Respiratory Diseases, Université de Montpellier, CHU Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Dominick Shaw
- Division of Respiratory Medicine, University of Nottingham, Nottingham, UK
| | | | - J Mark FitzGerald
- Centre for Heart and Lung Health, The Lung Centre Vancouver General Hospital, UBC Institute for Heart and Lung Health, Vancouver, Canada
| | - Eugene R Bleecker
- Divisions of Pharmacogenomics and Genetics, Genomics and Precision Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - William W Busse
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Gary T Ferguson
- Pulmonary Medicine, Internal Medicine, Critical Care Medicine, Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Laura Brooks
- Research and Development, AstraZeneca, Gaithersburg, MD, USA
| | - Peter Barker
- Research and Development, AstraZeneca, Gaithersburg, MD, USA
| | | | - Ubaldo J Martin
- Research and Development, AstraZeneca, Gaithersburg, MD, USA
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Young B, Cranwell J, Fogarty AW, Skelly R, Sturrock N, Norwood M, Shaw D, Lewis S, Langley T, Thurley P. Evaluation of the impact of a brief educational message on clinicians' awareness of risks of ionising-radiation exposure in imaging investigations: a pilot pre-post intervention study. BMC Health Serv Res 2019; 19:841. [PMID: 31727071 PMCID: PMC6857139 DOI: 10.1186/s12913-019-4712-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 06/13/2019] [Accepted: 11/05/2019] [Indexed: 11/28/2022] Open
Abstract
Background In the context of increasing availability of computed tomography (CT) scans, judicious use of ionising radiation is a priority to minimise the risk of future health problems. Hence, education of clinicians on the risks and benefits of CT scans in the management of patients is important. Methods An educational message about the associated lifetime cancer risk of a CT scan was added to all CT scan reports at a busy acute teaching hospital in the UK. An online multiple choice survey was completed by doctors before and after the intervention, assessing education and knowledge of the risks involved with exposure to ionising radiation. Results Of 546 doctors contacted at baseline, 170 (31%) responded. Over a third (35%) of respondents had received no formal education on the risks of exposure to ionising radiation. Over a quarter (27%) underestimated (selected 1 in 30,000 or negligible lifetime cancer risk) the risk associated with a chest, abdomen and pelvis CT scan for a 20 year old female. Following exposure to the intervention for 1 year there was a statistically significant improvement in plausible estimates of risk from 68.3 to 82.2% of respondents (p < 0.001). There was no change in the proportion of doctors correctly identifying imaging modalities that do or do not involve ionising radiation. Conclusions Training on the longterm risks associated with diagnostic radiation exposure is inadequate among hospital doctors. Exposure to a simple non-directional educational message for 1 year improved doctors’ awareness of risks associated with CT scans. This demonstrates the potential of the approach to improve knowledge that could improve clinical practice. This approach is easily deliverable and may have applications in other areas of clinical medicine. The wider and longer term impact on radiation awareness is unknown, however, and there may be a need for regular mandatory training in the risks of radiation exposure.
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Affiliation(s)
- Ben Young
- Division of Epidemiology and Public Health, Clinical Sciences Building, Nottingham City Hospital, University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK.
| | - Jo Cranwell
- Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK
| | - Andrew W Fogarty
- Division of Epidemiology and Public Health, Clinical Sciences Building, Nottingham City Hospital, University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Rob Skelly
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Nigel Sturrock
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Mark Norwood
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Dominick Shaw
- NIHR Nottingham Biomedical Research Centre, Clinical Sciences Building, Nottingham City Hospital, University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health, Clinical Sciences Building, Nottingham City Hospital, University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Tessa Langley
- Division of Epidemiology and Public Health, Clinical Sciences Building, Nottingham City Hospital, University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Peter Thurley
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
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Martindale S, Golightly D, Pinchin J, Shaw D, Blakey J, Perez I, Sharples S. An interview analysis of coordination behaviours in Out-of-Hours secondary care. Appl Ergon 2019; 81:102861. [PMID: 31422271 DOI: 10.1016/j.apergo.2019.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 03/19/2019] [Accepted: 05/22/2019] [Indexed: 06/10/2023]
Abstract
This paper seeks to elicit and structure the factors that shape the execution and, in particular, the coordination of work in Out of Hours care. Evenings and weekends in UK hospitals are managed by specific Out of Hours (OoH) care arrangements, and associated technology. Managing care within the constraints of staff availability and demands is a key concern for both patient care and staff wellbeing, yet has received little attention from healthcare human factors. A study of sixteen clinical staff used Critical Decision Method to understand how work is coordinated and the constraints and criteria that are applied by the roles managing OoH care. The analysis identified ten types of coordination decision that, in turn, underpinned three types of adaptive behaviour - pre-emption, information augmentation and self-organisation - that were crucial for the effective performance in OoH care. These behaviours explain how OoH staff manage the task demands placed on them, individually and as a team.
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Affiliation(s)
- Sarah Martindale
- Human Factors Research Group/Horizon Digital Economy Research, University of Nottingham, Nottingham, United Kingdom.
| | - David Golightly
- Faculty of Engineering, University of Nottingham, Nottingham, United Kingdom.
| | - James Pinchin
- Human Factors Research Group/Horizon Digital Economy Research, University of Nottingham, Nottingham, United Kingdom; Faculty of Engineering, University of Nottingham, Nottingham, United Kingdom
| | - Dominick Shaw
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, United Kingdom
| | - John Blakey
- Sir Charles Gairdner Hospital, Perth, Australia; Curtin University Medical School, Perth, Australia
| | - Iker Perez
- Human Factors Research Group/Horizon Digital Economy Research, University of Nottingham, Nottingham, United Kingdom
| | - Sarah Sharples
- Faculty of Engineering, University of Nottingham, Nottingham, United Kingdom
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Lewis S, Young B, Thurley P, Shaw D, Cranwell J, Skelly R, Langley T, Norwood M, Sturrock ND, Fogarty AW. Does cost feedback modify demand for common blood tests in secondary care? A prospective controlled intervention study. Future Healthc J 2019; 6:204-208. [PMID: 31660527 DOI: 10.7861/fhj.2019-0001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Behavioural insights or 'nudge' theory suggests that non-directional interventions may be used to modify human behaviour. We have tested the hypothesis that the provision of the cost of common blood tests with their results may modify subsequent demand for blood assays. Methods The study design was a prospective controlled intervention study. The individual and annual institutional cost of full blood count (FBC), urea and electrolytes (U&E) and liver function test (LFT) blood assays were added to the electronic results system for inpatients at the intervention teaching hospital, but not the control hospital. Results In the 12 months after the intervention was implemented, demand for FBC dropped by 3% (95% confidence interval (CI) 1-5; p<0.001), U&E by 2% (95% CI 0-4; p=0.054) and there was no change in demand for LFT compared to the control institution. Conclusions Providing cost feedback to clinicians for commonly used blood tests is a viable intervention that is associated with small reductions in demand for some, but not all blood assays. As this is an easily scalable approach, this has potential to enable efficient healthcare delivery, while also minimising the morbidity experienced by the patient.
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Affiliation(s)
| | - Ben Young
- University of Nottingham, Nottingham, UK
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Clifford RL, Patel J, MacIsaac JL, McEwen LM, Johnson SR, Shaw D, Knox AJ, Hackett TL, Kobor MS. Airway epithelial cell isolation techniques affect DNA methylation profiles with consequences for analysis of asthma related perturbations to DNA methylation. Sci Rep 2019; 9:14409. [PMID: 31595000 PMCID: PMC6783553 DOI: 10.1038/s41598-019-50873-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/15/2019] [Indexed: 12/14/2022] Open
Abstract
The airway epithelium forms the interface between the inhaled environment and the lung. The airway epithelium is dysfunctional in asthma and epigenetic mechanisms are considered a contributory factor. We hypothesised that the DNA methylation profiles of cultured primary airway epithelial cells (AECs) would differ between cells isolated from individuals with asthma (n = 17) versus those without asthma (n = 16). AECs were isolated from patients by two different isolation techniques; pronase digestion (9 non-asthmatic, 8 asthmatic) and bronchial brushings (7 non-asthmatic and 9 asthmatic). DNA methylation was assessed using an Illumina Infinium HumanMethylation450 BeadChip array. DNA methylation of AECs clustered by isolation technique and linear regression identified 111 CpG sites differentially methylated between isolation techniques in healthy individuals. As a consequence, the effect of asthmatic status on DNA methylation was assessed within AEC samples isolated using the same technique. In pronase isolated AECs, 15 DNA regions were differentially methylated between asthmatics and non-asthmatics. In bronchial brush isolated AECs, 849 differentially methylated DNA regions were identified with no overlap to pronase regions. In conclusion, regardless of cell isolation technique, differential DNA methylation was associated with asthmatic status in AECs, providing further evidence for aberrant DNA methylation as a signature of epithelial dysfunction in asthma.
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Affiliation(s)
- Rachel L Clifford
- Nottingham NIHR Biomedical Research Centre, Nottingham MRC Molecular Pathology Node, Division of Respiratory Medicine, University of Nottingham, Nottingham University Hospitals NHS Trust, Nottingham, UK. .,Centre for Molecular Medicine and Therapeutics, BC Children's Hospital Research Institute, Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Jamie Patel
- Nottingham NIHR Biomedical Research Centre, Nottingham MRC Molecular Pathology Node, Division of Respiratory Medicine, University of Nottingham, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Julia L MacIsaac
- Centre for Molecular Medicine and Therapeutics, BC Children's Hospital Research Institute, Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa M McEwen
- Centre for Molecular Medicine and Therapeutics, BC Children's Hospital Research Institute, Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Simon R Johnson
- Nottingham NIHR Biomedical Research Centre, Nottingham MRC Molecular Pathology Node, Division of Respiratory Medicine, University of Nottingham, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dominick Shaw
- Nottingham NIHR Biomedical Research Centre, Nottingham MRC Molecular Pathology Node, Division of Respiratory Medicine, University of Nottingham, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alan J Knox
- Nottingham NIHR Biomedical Research Centre, Nottingham MRC Molecular Pathology Node, Division of Respiratory Medicine, University of Nottingham, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tillie-Louise Hackett
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada.,Department of Anaesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Michael S Kobor
- Centre for Molecular Medicine and Therapeutics, BC Children's Hospital Research Institute, Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
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Lewis S, Young B, Thurley P, Shaw D, Cranwell J, Skelly R, Langley T, Norwood M, Sturrock N, Fogarty A. Evaluation of a nudge intervention providing simple feedback to clinicians of the consequence of radiation exposure on demand for computed tomography: a controlled study. Clin Med (Lond) 2019; 19:290-293. [PMID: 31308105 PMCID: PMC6752234 DOI: 10.7861/clinmedicine.19-4-290] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Computed tomography (CT) is readily available in developed countries. As one of the side effects includes an increased risk of cancer, interventions that may encourage more judicious use of CT are important. Behavioural economics theory includes the use of nudges that aim to help more informed decisions to be made, although these have been rarely used in hospitals to date. We aimed to evaluate the impact of a simple educational message appended to the CT report on subsequent numbers of CT completed using a controlled interrupted time series design based in two teaching hospitals in the UK. The intervention was the addition of a non-directional educational message on the risk of ionising radiation to all CT reports. There was a statistically significant reduction in the number of CT requested in the intervention hospital compared to the control hospital (-4.6%, 95% confidence intervals -7.4 to -1.7, p=0.002) in the 12 months after the intervention was implemented. We conclude that a simple, non-directional nudge intervention has the capacity to modify clinician use of CT. This approach is cheap, and has potential in helping support doctors make informed decisions.
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Affiliation(s)
| | | | | | | | | | - Rob Skelly
- University of Nottingham, Nottingham, UK
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Middleton S, Martindale S, Ryan M, Shaw D, Sharples S, Charnock A, Blakey J. Factors influencing task prioritisation by clinicians in hospital during out-of-hours periods. Future Healthc J 2019. [DOI: 10.7861/futurehealth.6-2-s23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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49
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Kuo CHS, Pavlidis S, Zhu J, Loza M, Baribaud F, Rowe A, Pandis I, Gibeon D, Hoda U, Sousa A, Wilson SJ, Howarth P, Shaw D, Fowler S, Dahlen B, Chanez P, Krug N, Sandstrom T, Fleming L, Corfield J, Auffray C, Djukanovic R, Sterk PJ, Guo Y, Adcock IM, Chung KF. Contribution of airway eosinophils in airway wall remodeling in asthma: Role of MMP-10 and MET. Allergy 2019; 74:1102-1112. [PMID: 30667542 DOI: 10.1111/all.13727] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 11/02/2018] [Accepted: 11/21/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Eosinophils play an important role in the pathophysiology of asthma being implicated in airway epithelial damage and airway wall remodeling. We determined the genes associated with airway remodeling and eosinophilic inflammation in patients with asthma. METHODS We analyzed the transcriptomic data from bronchial biopsies of 81 patients with moderate-to-severe asthma of the U-BIOPRED cohort. Expression profiling was performed using Affymetrix arrays on total RNA. Transcription binding site analysis used the PRIMA algorithm. Localization of proteins was by immunohistochemistry. RESULTS Using stringent false discovery rate analysis, MMP-10 and MET were significantly overexpressed in biopsies with high mucosal eosinophils (HE) compared to low mucosal eosinophil (LE) numbers. Immunohistochemical analysis confirmed increased expression of MMP-10 and MET in bronchial epithelial cells and in subepithelial inflammatory and resident cells in asthmatic biopsies. Using less-stringent conditions (raw P-value < 0.05, log2 fold change > 0.5), we defined a 73-gene set characteristic of the HE compared to the LE group. Thirty-three of 73 genes drove the pathway annotation that included extracellular matrix (ECM) organization, mast cell activation, CC-chemokine receptor binding, circulating immunoglobulin complex, serine protease inhibitors, and microtubule bundle formation pathways. Genes including MET and MMP10 involved in ECM organization correlated positively with submucosal thickness. Transcription factor binding site analysis identified two transcription factors, ETS-1 and SOX family proteins, that showed positive correlation with MMP10 and MET expression. CONCLUSION Pathways of airway remodeling and cellular inflammation are associated with submucosal eosinophilia. MET and MMP-10 likely play an important role in these processes.
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Affiliation(s)
- Chih-Hsi S. Kuo
- Airways Disease; National Heart & Lung Institute; Imperial College; London UK
- Biomedical Research Unit; Royal Brompton & Harefield NHS Trust; London UK
- Department of Computing & Data Science Institute; Imperial College; London UK
| | - Stelios Pavlidis
- Department of Computing & Data Science Institute; Imperial College; London UK
- Janssen Research and Development; High Wycombe UK
| | - Jie Zhu
- Airways Disease; National Heart & Lung Institute; Imperial College; London UK
| | - Matthew Loza
- Janssen Research and Development; High Wycombe UK
| | | | - Anthony Rowe
- Janssen Research and Development; High Wycombe UK
| | - Ioannis Pandis
- Airways Disease; National Heart & Lung Institute; Imperial College; London UK
- Biomedical Research Unit; Royal Brompton & Harefield NHS Trust; London UK
| | - David Gibeon
- Airways Disease; National Heart & Lung Institute; Imperial College; London UK
- Biomedical Research Unit; Royal Brompton & Harefield NHS Trust; London UK
| | - Uruj Hoda
- Department of Computing & Data Science Institute; Imperial College; London UK
| | - Ana Sousa
- Respiratory Therapeutic Unit; GlaxoSmithKline; Stockley Park UK
| | - Susan J. Wilson
- Faculty of Medicine; Southampton University; Southampton UK
- NIHR Southampton Respiratory Biomedical Research Unit; University Hospital Southampton; Southampton UK
| | - Peter Howarth
- Faculty of Medicine; Southampton University; Southampton UK
- NIHR Southampton Respiratory Biomedical Research Unit; University Hospital Southampton; Southampton UK
| | - Dominick Shaw
- Respiratory Research Unit; University of Nottingham; Nottingham UK
| | - Stephen Fowler
- Centre for Respiratory Medicine and Allergy; The University of Manchester; Manchester UK
| | - Barbro Dahlen
- The Centre for Allergy Research; The Institute of Environmental Medicine; Karolinska Institute; Stockholm Sweden
| | - Pascal Chanez
- Laboratoire d'immunologie; Département des Maladies Respiratoires; Aix Marseille Université Marseille; Marseille France
| | - Norbert Krug
- Immunology, Allergology and Clinical Inhalation; Fraunhofer Institute for Toxicology and Experimental Medicine; Hannover Germany
| | - Thomas Sandstrom
- Department of Medicine, Respiratory and Allergy unit; University Hospital; Umeå Sweden
| | - Louise Fleming
- Department of Computing & Data Science Institute; Imperial College; London UK
| | - Julie Corfield
- AstraZeneca R & D; Molndal Sweden
- Areteva R & D; Nottingham UK
| | - Charles Auffray
- European Institute for Systems Biology and Medicine; CNRS-ENS-UCBL; Université de Lyon; Lyon France
| | - Ratko Djukanovic
- Faculty of Medicine; Southampton University; Southampton UK
- NIHR Southampton Respiratory Biomedical Research Unit; University Hospital Southampton; Southampton UK
| | - Peter J. Sterk
- Faculty of Medicine; University of Amsterdam; Amsterdam The Netherland
| | - Yike Guo
- Department of Computing & Data Science Institute; Imperial College; London UK
| | - Ian M. Adcock
- Airways Disease; National Heart & Lung Institute; Imperial College; London UK
- Biomedical Research Unit; Royal Brompton & Harefield NHS Trust; London UK
| | - Kian Fan Chung
- Airways Disease; National Heart & Lung Institute; Imperial College; London UK
- Biomedical Research Unit; Royal Brompton & Harefield NHS Trust; London UK
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Middleton S, Martindale S, Ryan M, Shaw D, Sharples S, Charnock A, Blakey J. Factors influencing task prioritisation by clinicians in hospital during out-of-hours periods. Future Healthc J 2019; 6:23. [PMID: 31572921 PMCID: PMC6752408 DOI: 10.7861/futurehosp.6-2s-s23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
| | | | - Matt Ryan
- Aintree University Hospital, Liverpool, UK
| | - Dominick Shaw
- WayWard Project, University of Nottingham, Nottingham, UK
| | - Sarah Sharples
- WayWard Project, University of Nottingham, Nottingham, UK
| | | | - John Blakey
- Sir Charles Gardner Hospital, Perth, Australia
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