1
|
Kelly RJ, Holt M, Vidler J, Arnold LM, Large J, Forrest B, Barnfield C, Pike A, Griffin M, Munir T, Muus P, Nagumantry SK, Varghese A, Davies JR, Trikha R, Kulasekararaj AG, Mitchell L, Gandhi S. Treatment outcomes of complement protein C5 inhibition in 509 UK patients with paroxysmal nocturnal hemoglobinuria. Blood 2024; 143:1157-1166. [PMID: 38142401 DOI: 10.1182/blood.2023021762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/21/2023] [Accepted: 12/11/2023] [Indexed: 12/26/2023] Open
Abstract
ABSTRACT Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal hematopoietic disorder that occurs on a background of bone marrow failure (BMF). In PNH, chronic intravascular hemolysis causes an increase in morbidity and mortality, mainly because of thromboses. Over the last 20 years, treatment of PNH has focused on the complement protein C5 to prevent intravascular hemolysis using the monoclonal antibody eculizumab and more recently ravulizumab. In the United Kingdom, all patients are under review at 1 of 2 reference centers. We report on all 509 UK patients with PNH treated with eculizumab and/or ravulizumab between May 2002 and July 2022. The survival of patients with eculizumab and ravulizumab was significantly lower than that of age- and sex-matched controls (P = .001). Only 4 patients died of thromboses. The survival of patients with PNH (n = 389), when those requiring treatment for BMF (clonal evolution to myelodysplastic syndrome or acute leukemia or had progressive unresponsive aplastic anemia) were excluded, was not significantly different from that of age- and sex-matched controls (P = .12). There were 11 cases of meningococcal sepsis (0.35 events per 100 patient-years). Extravascular hemolysis was evident in patients who received treatment, with 26.7% of patients requiring transfusions in the most recent 12 months on therapy. Eculizumab and ravulizumab are safe and effective therapies that reduce mortality and morbidity in PNH, but further work is needed to reduce mortality in those with concomitant BMF.
Collapse
Affiliation(s)
- Richard J Kelly
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Matthew Holt
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Jennifer Vidler
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Louise M Arnold
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Joanna Large
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Briony Forrest
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Catherine Barnfield
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Alexandra Pike
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Morag Griffin
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Talha Munir
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Petra Muus
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Sateesh K Nagumantry
- Department of Haematology, Peterborough City Hospital, Peterborough, United Kingdom
| | - Abraham Varghese
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - John R Davies
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Roochi Trikha
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Lindsay Mitchell
- Department of Haematology, Monklands Hospital, Airdrie, United Kingdom
| | - Shreyans Gandhi
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
2
|
Fattizzo B, Gurnari C, Cassanello G, Bortolotti M, Awada H, Giammarco S, Consonni D, Sica S, Gandhi S, Trikha R, Large J, Salter S, Maciejewski JP, Barcellini W, Kulasekararaj AG. Deciphering treatment patterns in non-severe/moderate aplastic anemia: an international observational study. Leukemia 2023; 37:2479-2485. [PMID: 37794100 PMCID: PMC10681892 DOI: 10.1038/s41375-023-02047-z] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/06/2023]
Abstract
Non-severe aplastic anemia is a rare bone marrow failure disorder characterized by variable degrees and combination of cytopenias, with limited data on management and outcome. We describe a large multicentric series of 259 patients, focusing on clinical and molecular features, treatment, evolution, and survival. The majority required treatment with cyclosporine (CyA) alone (N = 84) or in combination with anti-thymocyte globulin (ATG,44) or eltrombopag (20), eltrombopag alone (10), or others (25) including androgens. Similar outcomes were observed across different strategies, with a 6-month overall response rate of 73% for CyA, 74% for ATG plus CyA, 68% for CyA plus eltrombopag, 87% for eltrombopag, and 79% for others. Notably, 56 patients (39%), mainly receiving CyA plus eltrombopag, achieved a trilineage response (p = 0.02). Progression to myeloid neoplasms was limited (8%) and not related to mutational status. Hemolytic PNH developed in 10% of cases, being predicted by detection of small clones at diagnosis. Survival was negatively impacted by age, male gender, LDH, platelets/erythrocyte transfusion need, and somatic mutations by NGS, and positively by higher neutrophils at diagnosis, PNH clones, and trilineage response at 6 and 12 months. Multivariable analysis confirmed the detrimental role of age and the favorable association with PNH clone and trilineage response at 6 months.
Collapse
Affiliation(s)
- Bruno Fattizzo
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Giulio Cassanello
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Bortolotti
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Hussein Awada
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sabrina Giammarco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Dario Consonni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Shreyans Gandhi
- Department of Hematological Medicine, King's College Hospital, London, UK
| | - Roochi Trikha
- Department of Hematological Medicine, King's College Hospital, London, UK
| | - Joanna Large
- Department of Hematological Medicine, King's College Hospital, London, UK
| | - Sarah Salter
- Department of Hematological Medicine, King's College Hospital, London, UK
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Austin G Kulasekararaj
- Department of Hematological Medicine, King's College Hospital, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| |
Collapse
|
3
|
Lazana I, Apap Mangion S, Babiker S, Large J, Trikha R, Zuckerman M, Gandhi S, Kulasekararaj AG. The Effect of Respiratory Viral Infections on Breakthrough Hemolysis in Patients with Paroxysmal Nocturnal Hemoglobinuria. Int J Mol Sci 2023; 24:ijms24119358. [PMID: 37298309 DOI: 10.3390/ijms24119358] [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: 02/15/2023] [Revised: 04/17/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by hemolysis and thrombosis and is associated with significant morbidity and mortality. Although complement inhibitors have significantly changed the outcomes in PNH patients, breakthrough hemolysis (BTH) may still occur as a response to stress factors such as pregnancy, surgery, and infections. Despite the well-described association between bacterial infections and hemolysis in PNH patients, little is known about the effect of respiratory viruses on triggering hemolytic episodes. This is the first study, to our knowledge, addressing this question. We retrospectively analyzed 34 patients with PNH disease between 2016 and 2018, who were on eculizumab treatment and who presented with respiratory symptoms and were subsequently tested for 10 respiratory viruses (influenza A, influenza B, parainfluenza, respiratory syncytial virus, adenovirus, rhinovirus, and human metapneumovirus). NTS+ patients had higher inflammatory markers, with the majority requiring antibiotics. Acute hemolysis, along with a significant drop in hemoglobin, was noted in the NTS+ group, with three of them requiring a top-up transfusion and two requiring an extra dose of eculizumab. Furthermore, the time from the last eculizumab dose was longer in the NTS+ patients who had BTH, than those who did not. Our data indicate that respiratory virus infections pose a significant risk for BTH in PNH patients on complement inhibitor treatment, underlining the need for regular screening and close monitoring of patients with respiratory symptoms. Furthermore, it implies a higher risk for patients who are not established on complement inhibitors, suggesting the necessity for greater vigilance in these patients.
Collapse
Affiliation(s)
- Ioanna Lazana
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
- Cell and Gene Therapy Laboratory, Biomedical Research Foundation of the Academy of Athens, 115 27 Athens, Greece
| | - Sean Apap Mangion
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
| | - Selma Babiker
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
| | - Joanna Large
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
| | - Roochi Trikha
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
| | - Mark Zuckerman
- Department of Virology, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Shreyans Gandhi
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
- Faculty of Life Sciences and Medicine, King's College London, London WC2R 2LS, UK
| | - Austin G Kulasekararaj
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
- Faculty of Life Sciences and Medicine, King's College London, London WC2R 2LS, UK
| |
Collapse
|
4
|
Debureaux PE, Kulasekararaj AG, Cacace F, Silva BGP, Calado RT, Barone F, Sicre de Fontbrune F, Prata PH, Soret J, Sica M, Notaro R, Scheinberg P, Mallikarjuna V, Gandhi S, Large J, Risitano AM, Peffault de Latour R, Frieri C. Categorizing hematological response to eculizumab in paroxysmal nocturnal hemoglobinuria: a multicenter real-life study. Bone Marrow Transplant 2021; 56:2600-2602. [PMID: 34226670 DOI: 10.1038/s41409-021-01372-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/12/2021] [Accepted: 06/01/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Pierre-Edouard Debureaux
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint-Louis hospital, Paris, France.
| | - Austin G Kulasekararaj
- Department of Hematological Medicine, King's College Hospital, National Institute of Health Research/Welcome King's Clinical Research Facility and King's College London, London, United Kingdom.,Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden, the Netherlands
| | - Fabiana Cacace
- Federico II University of Naples, Department of Clinical Medicine and Surgery, Naples, Italy
| | - Bruno G P Silva
- Department of Medical Imaging, Hematology, and Oncology, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Rodrigo T Calado
- Department of Medical Imaging, Hematology, and Oncology, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Federica Barone
- Laboratory of Cancer Genetics and Gene Transfer, Core Research Laboratory - Istituto per lo Studio, la Prevenzione e la Rete Oncologica (ISPRO), Florence, Italy.,Department of Hematology, University of Florence, Florence, Italy
| | - Flore Sicre de Fontbrune
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint-Louis hospital, Paris, France
| | - Pedro Henrique Prata
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint-Louis hospital, Paris, France.,Department of Medical Imaging, Hematology, and Oncology, University of São Paulo, Ribeirão Preto, SP, Brazil.,University of Paris, Paris, France
| | - Juliette Soret
- Clinical investigation center, Saint-Louis Hospital, Paris, France
| | - Michela Sica
- Department of Hematology, University of Florence, Florence, Italy
| | - Rosario Notaro
- Laboratory of Cancer Genetics and Gene Transfer, Core Research Laboratory - Istituto per lo Studio, la Prevenzione e la Rete Oncologica (ISPRO), Florence, Italy
| | - Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, Sao Paulo, Brazil
| | - Vasundhara Mallikarjuna
- Department of Hematological Medicine, King's College Hospital, National Institute of Health Research/Welcome King's Clinical Research Facility and King's College London, London, United Kingdom
| | - Shreyans Gandhi
- Department of Hematological Medicine, King's College Hospital, National Institute of Health Research/Welcome King's Clinical Research Facility and King's College London, London, United Kingdom
| | - Joanna Large
- Department of Hematological Medicine, King's College Hospital, National Institute of Health Research/Welcome King's Clinical Research Facility and King's College London, London, United Kingdom
| | - Antonio M Risitano
- Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden, the Netherlands.,Federico II University of Naples, Department of Clinical Medicine and Surgery, Naples, Italy.,AORN Moscati, Hematology and Transplant Unit, Avellino, Italy
| | - Regis Peffault de Latour
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint-Louis hospital, Paris, France.,Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden, the Netherlands.,University of Paris, Paris, France
| | - Camilla Frieri
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint-Louis hospital, Paris, France.,Federico II University of Naples, Department of Clinical Medicine and Surgery, Naples, Italy
| | | |
Collapse
|
5
|
Fattizzo B, Ireland R, Dunlop A, Yallop D, Kassam S, Large J, Gandhi S, Muus P, Manogaran C, Sanchez K, Consonni D, Barcellini W, Mufti GJ, Marsh JCW, Kulasekararaj AG. Clinical and prognostic significance of small paroxysmal nocturnal hemoglobinuria clones in myelodysplastic syndrome and aplastic anemia. Leukemia 2021; 35:3223-3231. [PMID: 33664463 PMCID: PMC8550969 DOI: 10.1038/s41375-021-01190-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [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: 02/15/2020] [Revised: 01/22/2021] [Accepted: 02/08/2021] [Indexed: 11/21/2022]
Abstract
In this large single-centre study, we report high prevalence (25%) of, small (<10%) and very small (<1%), paroxysmal nocturnal hemoglobinuria (PNH) clones by high-sensitive cytometry among 3085 patients tested. Given PNH association with bone marrow failures, we analyzed 869 myelodysplastic syndromes (MDS) and 531 aplastic anemia (AA) within the cohort. PNH clones were more frequent and larger in AA vs. MDS (p = 0.04). PNH clone, irrespective of size, was a good predictor of response to immunosuppressive therapy (IST) and to stem cell transplant (HSCT) (in MDS: 84% if PNH+ vs. 44.7% if PNH−, p = 0.01 for IST, and 71% if PNH+ vs. 56.6% if PNH− for HSCT; in AA: 78 vs. 50% for IST, p < 0.0001, and 97 vs. 77%, p = 0.01 for HSCT). PNH positivity had a favorable impact on disease progression (0.6% vs. 4.9% IPSS-progression in MDS, p < 0.005; and 2.1 vs. 6.9% progression to MDS in AA, p = 0.01), leukemic evolution (6.8 vs. 12.7%, p = 0.01 in MDS), and overall survival [73% (95% CI 68–77) vs. 51% (48–54), p < 0.0001], with a relative HR for mortality of 2.37 (95% CI 1.8–3.1; p < 0.0001) in PNH negative cases, both in univariate and multivariable analysis. Our data suggest systematic PNH testing in AA/MDS, as it might allow better prediction/prognostication and consequent clinical/laboratory follow-up timing.
Collapse
Affiliation(s)
- Bruno Fattizzo
- Department of Hematological medicine, King's College Hospital, London, UK.,Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy.,Department of Oncology and Onco-hematology, University of Milan, Milan, Italy
| | - Robin Ireland
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Alan Dunlop
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Deborah Yallop
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Shireen Kassam
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Joanna Large
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Shreyans Gandhi
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Petra Muus
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Charles Manogaran
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Katy Sanchez
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Dario Consonni
- Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Wilma Barcellini
- Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Ghulam J Mufti
- Department of Hematological medicine, King's College Hospital, London, UK.,Hematological Medicine, King's College London, London, UK
| | - Judith C W Marsh
- Department of Hematological medicine, King's College Hospital, London, UK.,Hematological Medicine, King's College London, London, UK
| | - Austin G Kulasekararaj
- Department of Hematological medicine, King's College Hospital, London, UK. .,Hematological Medicine, King's College London, London, UK.
| |
Collapse
|
6
|
Kulasekararaj AG, Lazana I, Large J, Posadas K, Eagleton H, Lord Villajin J, Zuckerman M, Gandhi S, Marsh JCW. Terminal complement inhibition dampens the inflammation during COVID-19. Br J Haematol 2020; 190:e141-e143. [PMID: 32495372 PMCID: PMC7300670 DOI: 10.1111/bjh.16916] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital-NHS Foundation Trust, London, UK.,NIHR/Wellcome King's Clinical Research Facility, London, UK.,King's College London, London, UK
| | - Ioanna Lazana
- Department of Haematological Medicine, King's College Hospital-NHS Foundation Trust, London, UK
| | - Joanna Large
- Department of Haematological Medicine, King's College Hospital-NHS Foundation Trust, London, UK
| | | | - Helen Eagleton
- Department of Haematology, Stoke Mandeville Hospital, Buckinghamshire, UK
| | | | - Mark Zuckerman
- South London Specialist Virology Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Shreyans Gandhi
- Department of Haematological Medicine, King's College Hospital-NHS Foundation Trust, London, UK.,NIHR/Wellcome King's Clinical Research Facility, London, UK
| | - Judith C W Marsh
- Department of Haematological Medicine, King's College Hospital-NHS Foundation Trust, London, UK.,King's College London, London, UK
| |
Collapse
|
7
|
Spence JC, Purssell H, Large J, Hendriskz C, Ang YS. Endoscopy under general anaesthetic in patients with metabolic disorders. Br J Hosp Med (Lond) 2016; 77:664. [PMID: 27828740 DOI: 10.12968/hmed.2016.77.11.664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J C Spence
- Medical Student Manchester Medical School Faculty of Medical and Human Sciences University of Manchester Manchester
| | - H Purssell
- Core Medical Trainee Department of Gastroenterology Salford Royal NHS Foundation Trust Salford Greater Manchester
| | - J Large
- Consultant Anaesthetist Department of Anaesthesiology Salford Royal NHS Foundation Trust Salford Greater Manchester
| | - C Hendriskz
- Consultant in Transitional Metabolic Medicine Department of Transitional and Adult Metabolic Disorders Salford Royal NHS Foundation Trust Salford Greater Manchester
| | - Y S Ang
- Consultant Gastroenterologist Department of Gastroenterology Salford Royal NHS Foundation Trust Salford M6 8HD
| |
Collapse
|
8
|
Arya A, Silberbauer JS, Vrahimides J, Cheek E, Mitchell A, Boodhoo L, Pugh P, Large J, Bordoli G, Taggu W, Lloyd GW, Patel NR, Sulke AN. First time and repeat cardioversion of atrial tachyarrhythmias - a comparison of outcomes. Int J Clin Pract 2010; 64:1062-8. [PMID: 20642706 DOI: 10.1111/j.1742-1241.2009.02229.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Repeat cardioversion may be necessary in over 50% of patients with persistent atrial fibrillation (AF), but identifying responders remains challenging. This study evaluates the long-term success of direct current cardioversion (DCCV) and the clinical and echocardiographical parameters that influence them, in over 1000 sedation-cardioversion procedures undertaken at Eastbourne General Hospital between 1996 and 2006. METHODS A total of 770 patients of mean age (SD) 70.1(10.1) underwent 1013 DCCVs (first n = 665, repeat n = 348) for atrial tachyarrhythmias from 1996 to 2006. Time to persistent arrhythmia recurrence was compared between first and multiple DCCV, and the effect of age, gender, presence of heart disease, left atrial size, fractional shortening, arrhythmia duration, anti-arrhythmic drug therapy (AAD) and other concomitant cardiac medication was evaluated using the Kaplan-Meier method and Cox's Proportional-hazards model. RESULTS In all, 33% of first and 29% of repeat DCCVs were in sinus rhythm (SR) at 12 months (m). There was no difference in median time to arrhythmia recurrence (SE) between first and multiple procedures: 1.5 +/- 0.1 m (1.3-1.7) and 1.5 +/- 0.0 m (1.4-1.6) respectively, p = 0.45. AAD use was significantly higher, arrhythmia duration shorter and more diabetic patients underwent repeat procedures. Amiodarone, OR 0.56, p = 0.04, sotalol, OR 0.61, p = 0.02 and arrhythmia duration, < 6 m, OR 0.72, p = 0.03 were independent predictors of improved outcome in first procedures only. In patients undergoing first procedures on amiodarone or sotalol, median time to arrhythmia recurrence was longer and 12 m SR rates higher, 6.0 +/- 2.4 m (42%) than those who had a repeat procedure on the same medication, 1.5 +/- 0.1 m (33%), p = 0.06. CONCLUSIONS The efficacy of first and subsequent DCCV procedures is similar, achieving a similar proportion of SR maintenance at 1 year. However, the benefits of AAD therapy are the greatest following first time procedures. Concomitant AAD therapy should be considered for all first time procedures for persistent AF.
Collapse
Affiliation(s)
- A Arya
- Cardiology Department, Eastbourne General Hospital, Eastbourne, UK
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
|
10
|
Smith CL, Milliken S, Powles R, Da Costa F, Gore M, Benjamin S, Talbot D, Ellis L, Large J, Jameson B. Teicoplanin compared to flucloxacillin for antibiotic treatment of neutropenic patients. Br J Haematol 1990; 76 Suppl 2:6-9. [PMID: 2149055 DOI: 10.1111/j.1365-2141.1990.tb07927.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Ninety-eight neutropenic patients were randomized to receive piperacillin and gentamicin in combination with either teicoplanin or flucloxacillin. Sixty-seven of these patients, most of whom had myeloma, were given this combination as prophylaxis 5 d after high dose chemotherapy, 35 receiving flucloxacillin and 32 receiving teicoplanin. Of 31 patients with leukaemia who were febrile and neutropenic following induction chemotherapy or bone marrow transplantation, 18 received flucloxacillin and 13 received teicoplanin. For those given flucloxacillin, the mean number of days to change of antibiotics was 7.8 in the prophylaxis group and 5.1 in the treatment group. In the teicoplanin arm, the mean number of days to change antibiotics was 6.8 in the prophylaxis group and 6.1 in the treatment group. Two patients in the flucloxacillin arm developed drug rashes. Four patients developed rigors after teicoplanin administration and one asthmatic became wheezy. One patient had a progressive rise in creatinine, but overall the patients having teicoplanin did not have any appreciable increase of renal toxicity compared to the flucloxacillin arm. Blood cultures were positive prior to commencement in the treatment group in nine patients, and during treatment in six patients. Organisms grown were Gram-positive in 14 patients. Teicoplanin appears to be as effective as flucloxacillin when each is used in combination with piperacillin and gentamicin in the treatment of neutropenic patients, with similar rates of toxicity.
Collapse
Affiliation(s)
- C L Smith
- Leukaemia Unit, Royal Marsden Hospital, London
| | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
|
12
|
Abstract
A review of the important steps required in the surgical procedure for treatment of varicose veins suggests a protocol in which all damaged veins are removed by the stab avulsion technique, only veins with incompetent proximal valves are ligated, and the long saphenous vein is never removed unless it is too damaged to use for arterial grafting. With this protocol of selective conservation it is possible to preserve valuable undamaged major leg veins and at the same time treat varicose veins efficiently. A 3-year postoperative review of 171 patients with 295 affected limbs treated in this way was done by independent observers. They found a recurrence rate of only 10.5%. There is evidence to suggest that Doppler testing for proximal valve competence will further improve results in the future.
Collapse
|
13
|
Abstract
It is believed that many surgeons, by adopting 'stripping' as the routine surgical treatment of significant varicose veins may be sacrificing many major leg veins which could be potentially valuable arterial grafts. A protocol of surgery is suggested which replaces stripping by the stab-avulsion technique. Thus all varices are removed and distal incompetent perforators controlled. Freed from an inevitable 'high ligation', it enables selective ligation at proximal valves, only when they are incompetent. It is suggested that this protocol treats varices effectively whilst preserving undamaged veins. The results presented show a 3 year recurrence rate of about 10%, but evidence is offered that better results will be obtained, now that Doppler equipment is readily available.
Collapse
|
14
|
Abstract
The recovery of muscle weight and contraction tension was measured in rat anterior tibialis muscle following unilateral crushing of the lateral popliteal nerve. Muscle twitch and tetanic tensions and muscle weight had recovered to control values within 6-8 weeks after the nerve was crushed. Capillary supply to each of the four types of muscle fibre present in the intact muscle, and within the groups of adjacent fibres of similar histochemical reaction for succinate dehydrogenase and myofibrillar actomyosin ATPase found in the reinnervated muscle, was computed by the method of Gray & Renkin (1978). Capillary area density (capillaries/mm2) within the grouped regions of the reinnervated muscle was not significantly different from the supply to the same fibre type in intact contralateral muscles. Capillary/fibre ratio for the more glycolytic fibre types (alpha W, alpha?) was lower than in intact muscle, while the values for both alpha R and beta R oxidative fibres agreed closely with control values. It seems that selective growth and loss of capillaries occurs during reinnervation, adjusting capillary supply to meet the changed metabolic demands of the individual fibres following regrouping.
Collapse
|
15
|
Abstract
While it is rational to ligate incompetent proximal saphenous valves, when treating varicose veins, it is hard to justify ligation if they are competent. Accurate diagnosis of competence by clinical tests have proved less than satisfactory. Doppler testing, with a simple blood flow indicator, is suggested as a sound basis on which to make decisions regarding 'selective ligations' of incompetent proximal valves.
Collapse
|
16
|
Large J, Murry T. Quantitative analysis of chant in relation to normal phonation and vocal fry. Folia Phoniatr (Basel) 1980; 32:14-22. [PMID: 7380368 DOI: 10.1159/000264320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
17
|
|
18
|
|
19
|
|
20
|
Large J, Iwata S, von Leden H. The primary female register transition in singing. Aerodynamic study. Folia Phoniatr (Basel) 1970; 22:385-96. [PMID: 5502872 DOI: 10.1159/000263418] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
21
|
Large J. Compression sclerotherapy in the treatment of varicose veins: an initial assessment. Med J Aust 1969; 2:840-5. [PMID: 5352867 DOI: 10.5694/j.1326-5377.1969.tb107575.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
22
|
Large J, Campbell W. An approach to the treatment of varicose veins. Med J Aust 1969; 2:212-3. [PMID: 5804222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
23
|
|