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O'Sullivan T, Craciun A, Byth K, Gupta S, Gauci JL, Cronin O, Whitfield A, Abuarisha M, Williams SJ, Lee EYT, Burgess NG, Bourke MJ. A simplified algorithm to evaluate the risk of submucosal invasive cancer in large (≥20 mm) nonpedunculated colonic polyps. Endoscopy 2024. [PMID: 38447957 DOI: 10.1055/a-2282-4794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND Recognition of submucosal invasive cancer (SMIC) in large (≥20 mm) nonpedunculated colonic polyps (LNPCPs) informs selection of the optimal resection strategy. LNPCP location, morphology, and size influence the risk of SMIC; however, currently no meaningful application of this information has simplified the process to make it accessible and broadly applicable. We developed a decision-making algorithm to simplify the identification of LNPCP subtypes with increased risk of potential SMIC. METHODS Patients referred for LNPCP resection from September 2008 to November 2022 were enrolled. LNPCPs with SMIC were identified from endoscopic resection specimens, lesion biopsies, or surgical outcomes. Decision tree analysis of lesion characteristics identified in multivariable analysis was used to create a hierarchical classification of SMIC prevalence. RESULTS 2451 LNPCPs were analyzed: 1289 (52.6%) were flat, 1043 (42.6%) nodular, and 118 (4.8%) depressed. SMIC was confirmed in 273 of the LNPCPs (11.1%). It was associated with depressed and nodular vs. flat morphology (odds ratios [ORs] 35.7 [95%CI 22.6-56.5] and 3.5 [95%CI 2.6-4.9], respectively; P<0.001); rectosigmoid vs. proximal location (OR 3.2 [95%CI 2.5-4.1]; P<0.001); nongranular vs. granular appearance (OR 2.4 [95%CI 1.9-3.1]; P<0.001); and size (OR 1.12 per 10-mm increase [95%CI 1.05-1.19]; P<0.001). Decision tree analysis targeting SMIC identified eight terminal nodes: SMIC prevalence was 62% in depressed LNPCPs, 19% in nodular rectosigmoid LNPCPs, and 20% in nodular proximal colon nongranular LNPCPs. CONCLUSIONS This decision-making algorithm simplifies identification of LNPCPs with an increased risk of potential SMIC. When combined with surface optical evaluation, it facilitates accurate lesion characterization and resection choices.
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Affiliation(s)
- Timothy O'Sullivan
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Ana Craciun
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Gastroenterology and Hepatology, Centro Hospitalar Universitario de Lisboa Norte, Lisboa, Portugal
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, Australia
- The NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- The University of Sydney Westmead Clinical School, Sydney, Australia
| | | | - Oliver Cronin
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Anthony Whitfield
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- The University of Sydney Westmead Clinical School, Sydney, Australia
| | | | | | - Eric Yong Tat Lee
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Nicholas Graeme Burgess
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Michael J Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- The University of Sydney Westmead Clinical School, Sydney, Australia
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Gough E, Ashworth S, Moodie T, Wang W, Byth K, Beldham-Collins R, Buck J, Ghattas S, Burke L, Stuart KE. DIBH reduces right coronary artery and lung radiation dose in right breast cancer loco-regional radiotherapy. Med Dosim 2024:S0958-3947(24)00016-5. [PMID: 38584019 DOI: 10.1016/j.meddos.2024.03.002] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/23/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024]
Abstract
To determine whether deep inspiratory breath-hold (DIBH) reduces dose to organs-at-risk (OAR), in particular the right coronary artery (RCA), in women with breast cancer requiring right-sided post-mastectomy radiotherapy (PMRT) including internal mammary chain (+IMC) radiotherapy (RT). Fourteen consecutive women requiring right-sided PMRT + IMC were retrospectively identified. Nodal delineation was in accordance with European Society for Radiology and Oncology (ESTRO) guidelines and tangential chest wall fields marked. Patients were planned with Anisotropic Analytical Algorithm using free-breathing (FB) and DIBH datasets. Dose was calculated using Acuros External Beam algorithm. FB and DIBH dose comparisons were analyzed for heart, RCA and right lung, as were chest wall and IMC planning target volumes (PTVs). DIBH vs FB resulted in median decreases of: the RCA mean dose by 0.6Gray (Gy) (interquartile range (IQR) 0.1, 1.9) (p = 0.002), RCA max dose by 1.8Gy (IQR 0.8, 6.1) (p = 0.002), and V5Gy by 2.9% (IQR 0.0, 37.2) (p = 0.016). RCA data indicated no statistically significant dosimetric reduction ≥10Gy. A median reduction of 1.7Gy (c -0.0, 7.1) (p = 0.019) in maximum heart dose was recorded with DIBH vs FB; no significant difference was observed in other heart and left anterior descending coronary artery parameters. The median reduction in right lung mean dose was 2.8Gy for DIBH vs FB plans (IQR 1.6, 3.6) (p = 0.001); significant median reductions of V5Gy, V20Gy, and V30Gy were all achieved with DIBH. Chest wall PTV coverage did not significantly differ between DIBH and FB plans; IMC dosimetric coverage improved with use of DIBH (V47.5Gy, V45Gy, V42Gy). DIBH reduced OAR dose in right-sided PMRT + IMC patients. A novel finding was that DIBH decreased RCA dose. Heart and right lung dose were also decreased with DIBH, whilst optimally dosed PTVs were maintained.
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Affiliation(s)
- Ebony Gough
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW 2145, Australia; Department of Radiation Oncology, Blacktown Cancer and Haematology Centre, Blacktown Hospital, Blacktown, NSW 2148, Australia
| | - Simon Ashworth
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW 2145, Australia; Department of Radiation Oncology, Blacktown Cancer and Haematology Centre, Blacktown Hospital, Blacktown, NSW 2148, Australia
| | - Trevor Moodie
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW 2145, Australia; Department of Radiation Oncology, Blacktown Cancer and Haematology Centre, Blacktown Hospital, Blacktown, NSW 2148, Australia
| | - Wei Wang
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW 2145, Australia; Sydney Medical School, C24-Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia; Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - Karen Byth
- NHMRC Clinical Trials Centre, The University of Sydney, Camperdown, NSW 2050, Australia; Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Rachael Beldham-Collins
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW 2145, Australia; Department of Radiation Oncology, Blacktown Cancer and Haematology Centre, Blacktown Hospital, Blacktown, NSW 2148, Australia
| | - Jacqueline Buck
- Clinical Trials, Nepean and Blue Mountains Cancer Care Centre, Nepean Hospital, Kingswood, NSW 2747, Australia
| | - Samer Ghattas
- Department of Medical Radiology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Lucinda Burke
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Kirsty E Stuart
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW 2145, Australia; Sydney Medical School, C24-Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia; Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia.
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Perananthan V, Gupta S, Whitfield A, Craciun A, Cronin O, O'Sullivan T, Byth K, Sidhu M, Hourigan LF, Raftopoulos S, Burgess NG, Bourke MJ. Correction: When less is more: lower esophageal sphincter-preserving peroral endoscopic myotomy is effective for non-achalasia esophageal motility disorders. Endoscopy 2024. [PMID: 38467157 DOI: 10.1055/a-2281-2969] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Affiliation(s)
- Varan Perananthan
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Anthony Whitfield
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Ana Craciun
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Gastroenterology and Hepatology, Centro Hospitalar Universitario de Lisboa Norte, Lisbon, Portugal
| | - Oliver Cronin
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Timothy O'Sullivan
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Karen Byth
- Western Sydney Local Health District Research and Education Network, Westmead Hospital, Westmead, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Australia
| | - Mayenaaz Sidhu
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Luke F Hourigan
- Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia
- Gallipoli Medical Research Institute, School of Medicine, The University of Queensland Greenslopes Clinical Unit, Brisbane, Australia
| | - Spiro Raftopoulos
- Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
- Faculty of Medicine, The University of Western Australia, Perth, Australia
- Faculty of Medicine, Curtin University, Perth, Australia
| | - Nicholas G Burgess
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Michael J Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
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Perananthan V, Gupta S, Whitfield A, Craciun A, Cronin O, O'Sullivan T, Byth K, Sidhu M, Hourigan LF, Raftopoulos S, Burgess NG, Bourke MJ. When less is more: lower esophageal sphincter-preserving peroral endoscopic myotomy is effective for non-achalasia esophageal motility disorders. Endoscopy 2024. [PMID: 38183976 DOI: 10.1055/a-2239-7371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2024]
Abstract
BACKGROUND Non-achalasia esophageal motility disorders (NAEMDs), encompassing distal esophageal spasm (DES) and hypercontractile esophagus (HCE), are rare conditions. Peroral endoscopic myotomy (POEM) is a promising treatment option. In NAEMDs, unlike with achalasia, the lower esophageal sphincter (LES) functions normally, suggesting the potential of LES preservation during POEM. METHODS This retrospective two-center observational study focused on patients undergoing LES-preserving POEM (LES-POEM) for NAEMD. Eckardt scores were assessed pre-POEM and at 6, 12, and 24 months post-POEM, with follow-up endoscopy at 6 months to evaluate for reflux esophagitis. Clinical success, defined as an Eckardt score ≤3, served as the primary outcome. RESULTS 227 patients were recruited over 84 months until May 2021. Of these, 16 underwent LES-POEM for an NAEMD (9 with HCE and 7 with DES). The median pre-POEM Eckardt score was 6.0 (interquartile range [IQR] 5.0-7.0), which decreased to 1.0 (IQR 0.0-1.8; P<0.001) 6 months post-POEM. This was sustained at 24 months, with an Eckardt score of 1.0 (IQR 0.0-1.8; P<0.001). Two patients (12.5%) developed Los Angeles grade A or B esophagitis. CONCLUSIONS LES-POEM for NAEMD demonstrates favorable clinical outcomes, with infrequent esophagitis and reintervention for LES dysfunction rarely required.
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Affiliation(s)
- Varan Perananthan
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Anthony Whitfield
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Ana Craciun
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Gastroenterology and Hepatology, Centro Hospitalar Universitario de Lisboa Norte, Lisbon, Portugal
| | - Oliver Cronin
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Timothy O'Sullivan
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Karen Byth
- Western Sydney Local Health District Research and Education Network, Westmead Hospital, Westmead, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Australia
| | - Mayenaaz Sidhu
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Luke F Hourigan
- Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia
- Gallipoli Medical Research Institute, School of Medicine, The University of Queensland Greenslopes Clinical Unit, Brisbane, Australia
| | - Spiro Raftopoulos
- Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
- Faculty of Medicine, The University of Western Australia, Perth, Australia
- Faculty of Medicine, Curtin University, Perth, Australia
| | - Nicholas G Burgess
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
| | - Michael J Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- School of Medicine, The University of Sydney Westmead Clinical School, Sydney, Australia
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O'Sullivan T, Sidhu M, Gupta S, Byth K, Elhindi J, Tate D, Cronin O, Whitfield A, Wang H, Lee E, Williams S, Burgess NG, Bourke MJ. A novel tool for case selection in endoscopic mucosal resection training. Endoscopy 2023; 55:1095-1102. [PMID: 37391184 DOI: 10.1055/a-2121-1148] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
BACKGROUND As endoscopic mucosal resection (EMR) of large (≥ 20 mm) adenomatous nonpedunculated colonic polyps (LNPCPs) becomes widely practiced outside expert centers, appropriate training is necessary to avoid failed resection and inappropriate surgical referral. No EMR-specific tool guides case selection for endoscopists learning EMR. This study aimed to develop an EMR case selection score (EMR-CSS) to identify potentially challenging lesions for "EMR-naïve" endoscopists developing competency. METHODS Consecutive EMRs were recruited from a single center over 130 months. Lesion characteristics, intraprocedural data, and adverse events were recorded. Challenging lesions with intraprocedural bleeding (IPB), intraprocedural perforation (IPP), or unsuccessful resection were identified and predictive variables identified. Significant variables were used to form a numerical score and receiver operating characteristic curves were used to generate cutoff values. RESULTS Of 1993 LNPCPs, 286 (14.4 %) were in challenging locations (anorectal junction, ileocecal valve, or appendiceal orifice), 368 (18.5 %) procedures were complicated by IPB and 77 (3.9 %) by IPP; 110 (5.5 %) procedures were unsuccessful. The composite end point of IPB, IPP, or unsuccessful EMR was present in 526 cases (26.4 %). Lesion size, challenging location, and sessile morphology were predictive of the composite outcome. A six-point score was generated with a cutoff value of 2 demonstrating 81 % sensitivity across the training and validation cohorts. CONCLUSIONS The EMR-CSS is a novel case selection tool for conventional EMR training, which identifies a subset of adenomatous LNPCPs that can be successfully and safely attempted in early EMR training.
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Affiliation(s)
- Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, New South Wales, Australia
- The NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - James Elhindi
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, New South Wales, Australia
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- University of Ghent, Ghent, Belgium
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Hunter Wang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Suenaga H, Schifter M, Chen N, Ali F, Byth K, Peck C. Impact of oral/dental disease burden on postoperative infective complications: a prospective cohort study. Clin Oral Investig 2023; 27:6461-6470. [PMID: 37730892 PMCID: PMC10630249 DOI: 10.1007/s00784-023-05251-4] [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: 06/15/2022] [Accepted: 09/09/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES This prospective cohort study aimed to assess the association between dental disease burden and postoperative infective complications (POICs) in patients undergoing major surgical procedures under general anaesthesia. METHODS Pre-surgical dental assessment was undertaken on patients planned for major surgery. Demographic and surgical variables including putative risk factors for POICs and POIC status were documented. The univariable association between POIC status and each factor was examined. Those variables associated at P value ≤ 0.2 were candidates for inclusion in multiple logistic regression models. Backward stepwise variable selection was used to identify the independent predictors for POIC in the best fitting logistic regression model. The area under the receiver operating curve (AUC) was used to quantify the model's global classification performance. RESULTS Among the 285 patients, 49 patients (17.2%) had POICs. The independent predictors for POIC were expected length of hospital stay (4-6 days; odds ratio [OR] = 4.80, 95% confidence internal [CI]: 1.30-17.70, P = 0.018, 7-9 days; OR = 5.42, 95% CI: 1.51-19.41, P = 0.009, ≥ 10 days; OR = 28.80, 95% CI: 4.12-201.18, P < 0.001), four or more decayed teeth (OR = 6.03, 95% CI: 2.28-15.94, P < 0.001) and visible tongue plaque (OR = 3.21, 95% CI: 1.54-6.70, P = 0.002). The AUC was 0.78 (95% CI: 0.71-0.85) indicating good discrimination. A simple screening tool for POIC was developed. CONCLUSIONS/CLINICAL RELEVANCE In addition to systemic/surgical factors, this study identified clinically detected decayed teeth and visible tongue plaque as independent predictors for POICs. Preoperative dental assessment/care might be beneficial to assess risk for POICs and improve postoperative outcomes.
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Affiliation(s)
- Hanako Suenaga
- Sydney Dental School, Faculty of Medicine and Health, The University of Sydney, Level 2-3 Westmead Centre for Oral Health, Westmead, NSW, 2145, Australia.
- Division of Advanced Prosthetic Dentistry, Tohoku University Graduate School of Dentistry, 4-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8575, Japan.
| | - Mark Schifter
- Sydney Dental School, Faculty of Medicine and Health, The University of Sydney, Level 2-3 Westmead Centre for Oral Health, Westmead, NSW, 2145, Australia
- Department of Oral Medicine, Oral Pathology and Special Needs Dentistry, Westmead Centre for Oral Health, Level 3, Westmead, NSW, 2145, Australia
| | - Nancy Chen
- Department of Oral Medicine, Oral Pathology and Special Needs Dentistry, Westmead Centre for Oral Health, Level 3, Westmead, NSW, 2145, Australia
| | - Farheen Ali
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Cnr Darcy & Hawkesbury Roads, Westmead, NSW, 2145, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Chris Peck
- Sydney Dental School, Faculty of Medicine and Health, The University of Sydney, Level 2-3 Westmead Centre for Oral Health, Westmead, NSW, 2145, Australia
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Deshmukh T, Kovoor JG, Byth K, Chow CK, Zaman S, Chong JJH, Figtree GA, Thiagalingam A, Kovoor P. Influence of standard modifiable risk factors on ventricular tachycardia after myocardial infarction. Front Cardiovasc Med 2023; 10:1283382. [PMID: 37942068 PMCID: PMC10628449 DOI: 10.3389/fcvm.2023.1283382] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/27/2023] [Indexed: 11/10/2023] Open
Abstract
Background Inducible ventricular tachycardia (VT) at electrophysiology study (EPS) predicts sudden cardiac death because of ventricular tachyarrhythmia, the single greatest cause of death within 2 years after myocardial infarction (MI). Objectives We aimed to assess the association between standard modifiable risk factors (SMuRFs) and inducible VT at EPS early after MI. Methods Consecutive patients with left ventricle ejection fraction ≤40% on days 3-5 after ST elevation MI (STEMI) who underwent EPS were prospectively recruited. Positive EPS was defined as induced sustained monomorphic VT cycle length ≥200 ms for ≥10 s or shorter if hemodynamically compromised. The primary outcome was inducibility of VT at EPS, and the secondary outcome was all-cause mortality on follow-up. Results In 410 eligible patients undergoing EPS soon (median of 9 days) after STEMI, 126 had inducible VT. Ex-smokers experienced an increased risk of inducible VT [multivariable logistic regression adjusted odds ratio (OR) 2.0, p = 0.033] compared with current or never-smokers, with comparable risk. The presence of any SMuRFs apart from being a current smoker conferred an increased risk of inducible VT (adjusted OR 1.9, p = 0.043). Neither the number of SMuRFs nor the presence of any SMuRFs was associated with mortality at a median follow-up of 5.4 years. Conclusions In patients with recent STEMI and impaired left ventricular function, the presence of any SMuRFs, apart from being a current smoker, conferred an increased risk of inducible VT at EPS. These results highlight the need to modify SMuRFs in this high-risk subset of patients.
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Affiliation(s)
- Tejas Deshmukh
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Centre for Heart Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Sydney, NSW, Australia
| | - Joshua G. Kovoor
- University of Adelaide, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, NSW, Australia
| | - Clara K. Chow
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, NSW, Australia
| | - Sarah Zaman
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, NSW, Australia
| | - James J. H. Chong
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Centre for Heart Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Sydney, NSW, Australia
| | - Gemma A. Figtree
- Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - Aravinda Thiagalingam
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, NSW, Australia
| | - Pramesh Kovoor
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, NSW, Australia
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Gebski V, Silva SSM, Byth K, Jenkins A, Keech A. Improving efficiency of fitting Cox proportional hazards models for time-to-event outcomes in genome-wide association studies (GWAS). Bioinform Adv 2023; 3:vbad148. [PMID: 37928342 PMCID: PMC10625458 DOI: 10.1093/bioadv/vbad148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 10/02/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
Summary Technologies identifying single nucleotide polymorphisms (SNPs) in DNA sequencing yield an avalanche of data requiring analysis and interpretation. Standard methods may require many weeks of processing time. The use of statistical methods requiring data sorting, matrix inversions of a high-dimension and replication in subsets of the data on multiple outcomes exacerbate these times.A method which reduces the computational time in problems with time-to-event outcomes and hundreds of thousands/millions of SNPs using Cox-Snell residuals after fitting the Cox proportional hazards model (PH) to a fixed set of concomitant variables is proposed. This yields coefficients for SNP effect from a Cox-Snell adjusted Poisson model and shows a high concordance to the adjusted PH model.The method is illustrated with a sample of 10 000 SNPs from a genome-wide association study in a diabetic population. The gain in processing efficiency using the proposed method based on Poisson modelling can be as high as 62%. This could result in saving of over three weeks processing time if 5 million SNPs require analysis. The method involves only a single predictor variable (SNP), offering a simpler, computationally more stable approach to examining and identifying SNP patterns associated with the outcome(s) allowing for a faster development of genetic signatures. Use of deviance residuals from the PH model to screen SNPs demonstrates a large discordance rate at a 0.2% threshold of concordance. This rate is 15 times larger than that based on the Cox-Snell residuals from the Cox-Snell adjusted Poisson model. Availability and implementation The method is simple to implement as the procedures are available in most statistical packges. The approach involves obtaining Cox-Snell residuals from a PH model, to a binary time-to-event outcome, for factors which need to be common when assessing each SNP. Each SNP is then fitted as a predictor to the outcome of interest using a Poisson model with the Cox-Snell as the exposure variable.
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Affiliation(s)
- Val Gebski
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW 1450, Australia
| | - S Sandun M Silva
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW 1450, Australia
| | - Karen Byth
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW 1450, Australia
| | - Alicia Jenkins
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW 1450, Australia
| | - Anthony Keech
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW 1450, Australia
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9
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Kovoor JG, Deshmukh T, von Huben A, Marschner SL, Byth K, Chow CK, Zaman S, Chong JJH, Thiagalingam A, Kovoor P. Optimizing electrophysiology studies to prevent sudden cardiac death after myocardial infarction. Europace 2023; 25:euad219. [PMID: 37470454 PMCID: PMC10374980 DOI: 10.1093/europace/euad219] [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: 04/17/2023] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023] Open
Abstract
AIMS This study assessed associations of minimum final extrastimulus coupling interval utilized within electrophysiology study (EPS) after myocardial infarction (MI) and possible site of origin of induced ventricular tachycardia (VT) with long-term occurrence of spontaneous ventricular tachyarrhythmia and long-term survival. METHODS AND RESULTS This prospective study recruited consecutive patients with left ventricular ejection fraction (LVEF) ≤ 40% who underwent EPS days 3-5 after MI between 2004 and 2017. Positive EPS was defined as sustained monomorphic VT cycle length ≥200 ms for ≥10 s or shorter duration if haemodynamic compromise occurred. Each of the four extrastimuli was shortened by 10 ms at a time, until it failed to capture the ventricle (ventricular refractoriness) or induced ventricular tachyarrhythmia. Outcomes included spontaneous ventricular tachyarrhythmia occurrence and all-cause mortality. Shorter coupling interval length of final extrastimulus that induced VT was associated with higher risk of spontaneous ventricular tachyarrhythmia (P < 0.001). Significantly higher rates of spontaneous ventricular tachyarrhythmia (65.2% vs. 23.2%; P < 0.001) were observed for final coupling interval at EPS <200 ms vs. >200 ms. Right bundle branch block (RBBB) morphology of induced VT, with possible site of origin from the left ventricle, was associated with all-cause mortality [hazard ratio (HR) 3.2, P = 0.044] and a composite of spontaneous ventricular tachyarrhythmia recurrence or mortality (HR 1.8, P = 0.043). CONCLUSION Ventricular tachycardia induced with shorter coupling intervals was associated with higher risk of spontaneous ventricular tachyarrhythymia on follow-up, indicating that the final extrastimulus coupling interval at EPS early after MI should be determined by ventricular refractoriness. Induced VT with possible origin from left ventricle was associated with increased risk of spontaneous ventricular tachyarrhythmia recurrence or death.
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MESH Headings
- Humans
- Stroke Volume/physiology
- Ventricular Function, Left
- Prospective Studies
- Defibrillators, Implantable/adverse effects
- Myocardial Infarction/complications
- Myocardial Infarction/diagnosis
- Cardiac Electrophysiology
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/prevention & control
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Death, Sudden, Cardiac/epidemiology
- Follow-Up Studies
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Affiliation(s)
- Joshua G Kovoor
- University of Adelaide, North Terrace, Adelaide, South Australia, 5005, Australia
- Queen Elizabeth Hospital, 28 Woodville Road, Adelaide, South Australia, 5011, Australia
| | - Tejas Deshmukh
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, 176 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia
- Department of Cardiology, Westmead Hospital, Corner Darcy and Hawkesbury Roads, Sydney, New South Wales 2145Australia
| | - Amy von Huben
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, 176 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia
- Department of Cardiology, Westmead Hospital, Corner Darcy and Hawkesbury Roads, Sydney, New South Wales 2145Australia
| | - Simone L Marschner
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, 176 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia
- Department of Cardiology, Westmead Hospital, Corner Darcy and Hawkesbury Roads, Sydney, New South Wales 2145Australia
| | - Karen Byth
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, 176 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia
- Department of Cardiology, Westmead Hospital, Corner Darcy and Hawkesbury Roads, Sydney, New South Wales 2145Australia
| | - Clara K Chow
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, 176 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia
- Department of Cardiology, Westmead Hospital, Corner Darcy and Hawkesbury Roads, Sydney, New South Wales 2145Australia
| | - Sarah Zaman
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, 176 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia
- Department of Cardiology, Westmead Hospital, Corner Darcy and Hawkesbury Roads, Sydney, New South Wales 2145Australia
| | - James J H Chong
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, 176 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia
- Department of Cardiology, Westmead Hospital, Corner Darcy and Hawkesbury Roads, Sydney, New South Wales 2145Australia
| | - Aravinda Thiagalingam
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, 176 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia
- Department of Cardiology, Westmead Hospital, Corner Darcy and Hawkesbury Roads, Sydney, New South Wales 2145Australia
| | - Pramesh Kovoor
- Centre for Heart Research, The Westmead Institute for Medical Research, The University of Sydney, 176 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia
- Department of Cardiology, Westmead Hospital, Corner Darcy and Hawkesbury Roads, Sydney, New South Wales 2145Australia
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10
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Ferkh A, Tjahjadi C, Stefani L, Geenty P, Byth K, De Silva K, Boyd AC, Richards D, Mollee P, Korczyk D, Taylor MS, Kwok F, Kizana E, Ng ACT, Thomas L. Cardiac "hypertrophy" phenotyping: differentiating aetiologies with increased left ventricular wall thickness on echocardiography. Front Cardiovasc Med 2023; 10:1183485. [PMID: 37465456 PMCID: PMC10351962 DOI: 10.3389/fcvm.2023.1183485] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/15/2023] [Indexed: 07/20/2023] Open
Abstract
Aims Differentiating phenotypes of cardiac "hypertrophy" characterised by increased wall thickness on echocardiography is essential for management and prognostication. Transthoracic echocardiography is the most commonly used screening test for this purpose. We sought to identify echocardiographic markers that distinguish infiltrative and storage disorders that present with increased left ventricular (LV) wall thickness, namely, cardiac amyloidosis (CA) and Anderson-Fabry disease (AFD), from hypertensive heart disease (HHT). Methods Patients were retrospectively recruited from Westmead Hospital, Sydney, and Princess Alexandra Hospital, Brisbane. LV structural, systolic, and diastolic function parameters, as well as global (LVGLS) and segmental longitudinal strains, were assessed. Previously reported echocardiographic parameters including relative apical sparing ratio (RAS), LV ejection fraction-to-strain ratio (EFSR), mass-to-strain ratio (MSR) and amyloidosis index (AMYLI) score (relative wall thickness × E/e') were evaluated. Results A total of 209 patients {120 CA [58 transthyretin amyloidosis (ATTR) and 62 light-chain (AL) amyloidosis], 31 AFD and 58 HHT patients; mean age 64.1 ± 13.7 years, 75% male} comprised the study cohort. Echocardiographic measurements differed across the three groups, The LV mass index was higher in both CA {median 126.6 [interquartile range (IQR) 106.4-157.9 g/m2]} and AFD [median 134 (IQR 108.8-152.2 g/m2)] vs. HHT [median 92.7 (IQR 79.6-102.3 g/m2), p < 0.05]. LVGLS was lowest in CA [median 12.29 (IQR 10.33-15.56%)] followed by AFD [median 16.92 (IQR 14.14-18.78%)] then HHT [median 18.56 (IQR 17.51-19.97%), p < 0.05]. Diastolic function measurements including average e' and E/e' were most impaired in CA and least impaired in AFD. Indexed left atrial volume was highest in CA. EFSR and MSR differentiated secondary (CA + AFD) from HHT [receiver operating curve-area under the curve (ROC-AUC) of 0.80 and 0.91, respectively]. RAS and AMYLI score differentiated CA from AFD (ROC-AUC of 0.79 and 0.80, respectively). A linear discriminant analysis with stepwise variable selection using linear combinations of LV mass index, average e', LVGLS and basal strain correctly classified 79% of all cases. Conclusion Simple echocardiographic parameters differentiate between different "hypertrophic" cardiac phenotypes. These have potential utility as a screening tool to guide further confirmatory testing.
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Affiliation(s)
- Aaisha Ferkh
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Catherina Tjahjadi
- Cardiology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Luke Stefani
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Paul Geenty
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Karen Byth
- WSLHD Research and Education Network, Westmead Hospital, Westmead, NSW, Australia
| | - Kasun De Silva
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Anita C. Boyd
- Westmead Private Cardiology, Westmead, NSW, Australia
| | | | - Peter Mollee
- Haematology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Dariusz Korczyk
- Cardiology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Mark S. Taylor
- Department of Clinical Immunology and Allergy, Westmead Hospital, Westmead, NSW, Australia
| | - Fiona Kwok
- Haematology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Eddy Kizana
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
- Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Arnold C. T. Ng
- Cardiology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Liza Thomas
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
- South-West Clinical School, University of New South Wales, Liverpool, NSW, Australia
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11
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Turnbull S, Garikapati K, Bennett RG, Campbell TG, Kotake Y, Mahajan R, Marschner S, Byth K, Chow CK, Kumar S. Utility of a Handheld, Single-Lead ECG Device for Diagnosis of Cardiac Arrhythmias. J Am Coll Cardiol 2023; 81:2292-2294. [PMID: 37286259 DOI: 10.1016/j.jacc.2023.03.428] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/02/2023] [Accepted: 03/31/2023] [Indexed: 06/09/2023]
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12
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Stewart AG, Chen SCA, Hamilton K, Harris-Brown T, Korman TM, Figtree M, Worth LJ, Kok J, Van der Poorten D, Byth K, Slavin MA, Paterson DL. Clostridioides difficile Infection: Clinical Practice and Health Outcomes in 6 Large Tertiary Hospitals in Eastern Australia. Open Forum Infect Dis 2023; 10:ofad232. [PMID: 37274181 PMCID: PMC10237225 DOI: 10.1093/ofid/ofad232] [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: 02/25/2023] [Accepted: 04/26/2023] [Indexed: 06/06/2023] Open
Abstract
Background Clostridioides difficile infection (CDI) is associated with significant morbidity and mortality in both healthcare and community settings. We aimed to define the predisposing factors, risks for severe disease, and mortality determinants of CDI in eastern Australia over a 1-year period. Methods This is an observational retrospective study of CDI in hospitalized patients aged ≥18 years in 6 tertiary institutions from 1 January 2016 to 31 December 2016. Patients were identified through laboratory databases and medical records of participating institutions. Clinical, imaging, and laboratory data were input into an electronic database hosted at a central site. Results A total of 578 patients (578 CDI episodes) were included. Median age was 65 (range, 18-99) years and 48.2% were male. Hospital-onset CDI occurred in 64.0%. Recent antimicrobial use (41.9%) and proton pump inhibitor use (35.8%) were common. Significant risk factors for severe CDI were age <65 years (P < .001), malignancy within the last 5 years (P < .001), and surgery within the previous 30 days (P < .001). Significant risk factors for first recurrence included severe CDI (P = .03) and inflammatory bowel disease (P = .04). Metronidazole was the most common regimen for first episodes of CDI with 65.2% being concordant with Australian treatment guidelines overall. Determinants for death at 60 days included age ≥65 years (P = .01), severe CDI (P < .001), and antibiotic use within the prior 30 days (P = .02). Of those who received metronidazole as first-line therapy, 10.1% died in the 60-day follow-up period, compared to 9.8% of those who received vancomycin (P = .86). Conclusions Patients who experience CDI are vulnerable and require early diagnosis, clinical surveillance, and effective therapy to prevent complications and improve outcomes.
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Affiliation(s)
- Adam G Stewart
- Correspondence: Adam Stewart, BBiomedSci, MBBS(Hons), MPHTM, Centre for Clinical Research, University of Queensland, Bldg 71/918 RBWH Herston, Brisbane, QLD 4029, Australia (); David Paterson, Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore 117549 ()
| | - Sharon C A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, Australia
- Department of Infectious Diseases, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Kate Hamilton
- Department of Infectious Diseases, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Tiffany Harris-Brown
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
| | - Tony M Korman
- Monash Infectious Diseases, Monash University and Monash Health, Melbourne, Australia
| | - Melanie Figtree
- Department of Infectious Diseases, Royal North Shore Hospital, Sydney, Australia
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Centre, Melbourne, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Jen Kok
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, Australia
| | | | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Sydney, Australia
- National Health and Medical Research Council Clinical Trials Centre, Sydney University, Sydney, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Centre, Melbourne, Australia
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Australia
| | - David L Paterson
- Correspondence: Adam Stewart, BBiomedSci, MBBS(Hons), MPHTM, Centre for Clinical Research, University of Queensland, Bldg 71/918 RBWH Herston, Brisbane, QLD 4029, Australia (); David Paterson, Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore 117549 ()
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13
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O'Sullivan T, Tate D, Sidhu M, Gupta S, Elhindi J, Byth K, Cronin O, Whitfield A, Craciun A, Singh R, Brown G, Raftopoulos S, Hourigan L, Moss A, Klein A, Heitman S, Williams S, Lee E, Burgess NG, Bourke MJ. The Surface Morphology of Large Nonpedunculated Colonic Polyps Predicts Synchronous Large Lesions. Clin Gastroenterol Hepatol 2023:S1542-3565(23)00101-5. [PMID: 36787836 DOI: 10.1016/j.cgh.2023.01.034] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND & AIMS Large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) may have synchronous LNPCPs in up to 18% of cases. The nature of this relationship has not been investigated. We aimed to examine the relationship between individual LNPCP characteristics and synchronous colonic LNPCPs. METHODS Consecutive patients referred for resection of LNPCPs over 130 months until March 2022 were enrolled. Serrated lesions and mixed granularity LNPCPs were excluded from analysis. Patients with multiple LNPCPs resected were identified, and the largest was labelled as dominant. The primary outcome was the identification of individual lesion characteristics associated with the presence of synchronous LNPCPs. RESULTS There were 3149 of 3381 patients (93.1%) who had a single LNPCP. In 232 (6.9%) a synchronous lesion was detected. Solitary lesions had a median size of 35 mm with a predominant Paris 0-IIa morphology (42.9%) and right colon location (59.5%). In patients with ≥2 LNPCPs, the dominant lesion had a median size of 40 mm, Paris 0-IIa (47.6%) morphology, and right colon location (65.9%). In this group, 35.8% of dominant LNPCPs were non-granular compared with 18.7% in the solitary LNPCP cohort. Non-granular (NG)-LNPCPs were more likely to demonstrate synchronous disease, with left colon NG-LNPCPs demonstrating greater risk (odds ratio, 4.78; 95% confidence interval, 2.95-7.73) than right colon NG-LNPCPs (odds ratio, 1.99; 95% confidence interval, 1.39-2.86). CONCLUSIONS We found that 6.9% of LNPCPs have synchronous disease, with NG-LNPCPs demonstrating a greater than 4-fold increased risk. With post-colonoscopy interval cancers exceeding 5%, endoscopists must be cognizant of an individual's LNPCP phenotype when examining the colon at both index procedure and surveillance. CLINICALTRIALS gov, NCT01368289; NCT02000141; NCT02198729.
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Affiliation(s)
- Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - David Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium; University of Ghent, Ghent, Belgium
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - James Elhindi
- WSLHD Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia
| | - Karen Byth
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; WSLHD Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Ana Craciun
- Departamento de Gastrenterologia e Hepatologia, Centro Hospitalar Universitario Lisboa Norte, Lisbon, Portugal
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Lyell McEwan Hospital, Adelaide, South Australia, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, VIC, Australia
| | - Spiro Raftopoulos
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Luke Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Department of Gastroenterology, Greenslopes Private Hospital, Gallipoli Medical Research Foundation, Brisbane, Queensland, Australia
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Victoria, Australia
| | - Amir Klein
- Ambam Heath Care Campus, Technion Institute of Technology, Haifa, Israel; Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Steven Heitman
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, AB, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
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Chai TY, Byth K, George J, Pasupathy D, Cheung NW. Elevated Hepatic Steatosis Index is Associated with the Development of Adverse Maternal, but Not Adverse Neonatal, Outcomes: A Retrospective Cohort Study. Int J Womens Health 2023; 15:589-598. [PMID: 37077282 PMCID: PMC10108907 DOI: 10.2147/ijwh.s399085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/15/2023] [Indexed: 04/21/2023] Open
Abstract
Objective To determine whether an elevated hepatic steatosis index (HSI), a non-invasive test for possible metabolic dysfunction-associated fatty liver disease (MAFLD), is associated with the development of adverse pregnancy outcomes. Material and Methods A retrospective cohort study was conducted on adult women with singleton pregnancies who delivered at two tertiary hospitals from August 2014 to December 2017. Aspartate aminotransaminase (AST) and alanine aminotransaminase (ALT) levels obtained 12 months pre-gravid, or during pregnancy but prior to screening for gestational diabetes mellitus (GDM), were extracted and linked with oral glucose tolerance test results. The HSI was calculated using the following equation: 8 × (ALT/AST ratio) + BMI (+2 if female; +2 if diabetes mellitus present) and considered elevated if >36. Multiple logistic regression analysis was used to quantify the association between elevated HSI and each composite adverse pregnancy outcome after adjusting for independent maternal risk factors. Results Over 40-months, 11929 women were eligible and of these, 1885 had liver enzymes collected. Women with an elevated HSI (>36) were more likely multiparous and overweight/obese compared to those women with a non-elevated HSI (≤36). Elevated HSI was significantly associated with a composite of adverse maternal outcomes (adjusted odds ratio (aOR) 1.55 95% CI 1.11-2.17, p=0.01), although a non-significant increased risk of a composite of adverse neonatal outcomes occurred after multivariable adjustment (aOR 1.17, 95% CI 0.94-1.45, p=0.17). Conclusion Over and above known maternal risk factors, women with elevated HSI were more likely to develop adverse maternal, but not adverse neonatal outcomes.
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Affiliation(s)
- Thora Y Chai
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Reproduction and Perinatal Centre, The University of Sydney, Sydney, NSW, Australia
- Correspondence: Thora Y Chai, Email
| | - Karen Byth
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Western Sydney Local Health District Research Education Network, Westmead, NSW, Australia
| | - Jacob George
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Storr Liver Centre, Westmead Millennium Institute for Medical Research, Westmead, NSW, Australia
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, NSW, Australia
| | - Dharmintra Pasupathy
- Reproduction and Perinatal Centre, The University of Sydney, Sydney, NSW, Australia
| | - N Wah Cheung
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Reproduction and Perinatal Centre, The University of Sydney, Sydney, NSW, Australia
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15
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Hannaford A, Byth K, Pavey N, Henderson RD, Mathers S, Needham M, Schultz D, Menon P, Kiernan MC, Vucic S. Clinical and neurophysiological biomarkers of disease progression in amyotrophic lateral sclerosis. Muscle Nerve 2023; 67:17-24. [PMID: 36214183 DOI: 10.1002/mus.27736] [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: 06/28/2022] [Revised: 10/04/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Rate of disease progression (ΔFS), measured as change in the revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) and body mass index (BMI), are predictors of survival in amyotrophic lateral sclerosis (ALS). Our aim in this study was to assess the utility of these clinical biomarkers along with neurophysiological measures, such as the split hand index (SI), in monitoring disease progression. METHODS Clinical trial data were collected from 107 patients recruited into the Tecfidera in ALS trial. The prognostic utility of clinical and neurophysiological measures, including ΔFS, BMI, SI, and neurophysiological index (NPI), were assessed cross-sectionally and longitudinally (40 weeks). The outcome measures of disease severity and progression included: (i) ALSFRS-R score; (ii) Medical Research Council (MRC) score; and (iii) forced vital capacity and sniff nasal inspiratory pressure. RESULTS Fast-progressor ALS patients (ΔFS ≥1.1) exhibited significantly lower ALSFRS-R and total MRC scores at baseline. A baseline ΔFS score ≥1.1 was associated with a greater reduction in ALSFRS-R (P = .002) and MRC (P = .002) scores over 40 weeks. Baseline BMI <25 was also associated with faster reduction of ALSFRS-R and MRC scores. SI and NPI were associated with disease severity at baseline, but not with subsequent rate of disease progression. DISCUSSION Implementation of the assessed clinical and neurophysiological biomarkers may assist in patient management and stratification into clinical trials.
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Affiliation(s)
- Andrew Hannaford
- Brain and Nerve Research Centre, Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- NHMRC Clinica Trials Center, Westmead Hospital, Research and Education Network, Westmead, New South Wales, Australia.,NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Nathan Pavey
- Brain and Nerve Research Centre, Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Robert D Henderson
- Department of Neurology, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Susan Mathers
- Department of Neurology, Calvary Health Care Bethlehem, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Merrilee Needham
- Department of Neurology, Fiona Stanley Hospital, Murdoch, Australia.,Centre for Molecular Medicine, Murdoch University, Perth, Western Australia, Australia.,Department of Neurology, Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia.,Department of Neurology, University of Notre Dame, Fremantle, Western Australia, Australia
| | - David Schultz
- Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Department of Neurology, Flinders University of South Australia, Bedford Park, South Australia, Australia
| | - Parvathi Menon
- Brain and Nerve Research Centre, Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Steve Vucic
- Brain and Nerve Research Centre, Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Chai TY, Deng D, Byth K, George J, Pasupathy D, Cheung NW. The prevalence of metabolic dysfunction-associated fatty liver disease and its association on adverse pregnancy outcomes in women with gestational diabetes mellitus. Diabetes Res Clin Pract 2022; 191:110038. [PMID: 35970401 DOI: 10.1016/j.diabres.2022.110038] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/21/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022]
Abstract
AIMS To determine the prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) and its association on adverse pregnancy outcomes in women with gestational diabetes mellitus (GDM). METHODS 380 women with GDM had a FibroScan® performed between 24 and 32 weeks. A Controlled Attenuation Parameter (CAP) ≥ 233.5 dB/m signified MAFLD. Gestational hypertension, pre-eclampsia and eclampsia contributed to a composite of adverse maternal outcomes. A composite of adverse neonatal outcomes included pre-term birth, hypoglycaemia, small/large-for-gestational age and admission to neonatal high dependency. Multiple logistic regression was used to determine independent associations with MAFLD. RESULTS 147 (38.7 %) women had MAFLD. Higher pre-pregnancy BMI (median 28.4, IQR 24.7-33.0 kg/m2 vs median 24.0, IQR 21.7-26.5 kg/m2, p < 0.01) and rates of insulin therapy (62.2 % vs 40.7 %, p < 0.01) occurred in MAFLD over non-MAFLD women. MAFLD was independently associated with obesity (aOR 4.73 [95 % CI 2.53-8.86]) and insulin therapy (aOR 1.79 [95 % CI 1.12-2.85]). MAFLD and non-MAFLD women had comparable rates of adverse maternal (7.7 % vs 9.5 %, p = 0.56) and neonatal outcomes (75.4 % vs 68.8 %, p = 0.18). CONCLUSIONS Within this GDM cohort, almost 40% had FibroScan®-detected MAFLD in mid-to-late gestation. MAFLD was not associated with worse pregnancy outcomes.
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Affiliation(s)
- Thora Y Chai
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Difei Deng
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Karen Byth
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Western Sydney Local Health District Research Education Network, Westmead, NSW, Australia.
| | - Jacob George
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Storr Liver Centre, Westmead Millennium Institute for Medical Research, Westmead, NSW, Australia; Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, NSW, Australia.
| | - Dharmintra Pasupathy
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Ngai Wah Cheung
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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17
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Cronin O, Sidhu M, Shahidi N, Gupta S, O'Sullivan T, Whitfield A, Wang H, Kumar P, Hourigan LF, Byth K, Burgess NG, Bourke MJ. Comparison of the morphology and histopathology of large nonpedunculated colorectal polyps in the rectum and colon: implications for endoscopic treatment. Gastrointest Endosc 2022; 96:118-124. [PMID: 35219724 DOI: 10.1016/j.gie.2022.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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] [Received: 10/01/2021] [Accepted: 02/15/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The risk of cancer in large nonpedunculated colorectal polyps ≥20 mm (LNPCPs) in the rectum relative to the remainder of the colon is unknown. We aimed to describe differences between rectal and colonic LNPCPs to better inform treatment decisions. METHODS Patients with LNPCPs referred to tertiary centers for endoscopic resection within a prospective, multicenter, observational cohort were evaluated. Data recorded were participant demographics, LNPCP location, morphology, resection modality, and histopathologic data. Multiple logistic regression analysis was used to identify those variables independently associated with rectal versus nonrectal location in the colon. RESULTS Patients with LNPCPs referred for endoscopic resection between July 2008 and July 2021 were included. Rectal LNPCPs (n = 618) were larger (median size, 40 mm vs 30 mm; P < .001) and more likely to be granular (79% vs 50%, P < .001) with a nodular component (53% vs 17%, P < .001) compared with nonrectal LNPCPs (n = 2787). Rectal LNPCPs were more likely to have tubulovillous histopathology (72% vs 47%, P < .001) and contain cancer (15% vs 6%, P < .001). After adjusting for the other features independently associated with location, cancer was more common in the rectum compared with the colon (odds ratio, 1.77; 95% confidence interval, 1.25-2.53). CONCLUSIONS This study suggests that compared with LNPCPs in the rest of the colon, rectal LNPCPs are more likely to be larger and contain more advanced pathology. These findings have implications for curative endoscopic resection techniques particularly where early cancer is present. (Clinical trial registration numbers: NCT01368289 and NCT02000141.).
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Affiliation(s)
- Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Hunter Wang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Puja Kumar
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Karen Byth
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Whitfield AM, Burgess NG, Bahin FF, Kabir S, Pellisé M, Sonson R, Subramanian V, Mahajan H, McLeod D, Byth K, Bourke MJ. Histopathological effects of electrosurgical interventions in an in vivo porcine model of colonic endoscopic mucosal resection. Gut 2022; 71:864-870. [PMID: 34172512 DOI: 10.1136/gutjnl-2021-324140] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/16/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Endoscopic mucosal resection (EMR) in the colon has been widely adopted, but there is limited data on the histopathological effects of the differing electrosurgical currents (ESCs) used. We used an in vivo porcine model to compare the tissue effects of ESCs for snare resection and adjuvant margin ablation techniques. DESIGN Standardised EMR was performed by a single endoscopist in 12 pigs. Two intersecting 15 mm snare resections were performed. Resections were randomised 1:1 using either a microprocessor-controlled current (MCC) or low-power coagulating current (LPCC). The lateral margins of each defect were treated with either argon plasma coagulation (APC) or snare tip soft coagulation (STSC). Colons were surgically removed at 72 hours. Two specialist pathologists blinded to the intervention assessed the specimens. RESULTS 88 defects were analysed (median 7 per pig, median defect size 29×17 mm). For snare ESC effects, 156 tissue sections were assessed. LPCC was comparable to MCC for deep involvement of the colon wall. For margin ablation, 172 tissue sections were assessed. APC was comparable to STSC for deep involvement of the colon wall. Islands of preserved mucosa at the coagulated margin were more likely with APC compared with STSC (16% vs 5%, p=0.010). CONCLUSION For snare resection, MCC and LPCC did not produce significantly different tissue effects. The submucosal injectate may protect the underlying tissue, and technique may more strongly dictate the depth and extent of final injury. For margin ablation, APC was less uniform and complete compared with STSC.
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Affiliation(s)
- Anthony M Whitfield
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Nicholas G Burgess
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Farzan F Bahin
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Sharir Kabir
- Department of General Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - María Pellisé
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Rebecca Sonson
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Vishnu Subramanian
- Department of General Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Hema Mahajan
- Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Duncan McLeod
- Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Karen Byth
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia.,WSLHD Research and Education Network, Westmead Hospital, Westmead, New South Wales, Australia
| | - Michael J Bourke
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia .,Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
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19
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Perry J, Byth K, Bullingham A. A retrospective cohort study of three wound catheter infusion analgesia regimes after midline laparotomy. Reg Anesth Pain Med 2022; 47:222-227. [DOI: 10.1136/rapm-2021-103098] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 12/31/2021] [Indexed: 11/09/2022]
Abstract
BackgroundLocal anesthetic wound infusion catheters are increasingly used postmidline laparotomy to reduce pain and opioid use, however there is little evidence to support any particular infusion regime.MethodsA retrospective cohort study was undertaken of patients after midline laparotomy who had bilateral local anesthetic wound infusion catheters surgically placed. Patients were recruited into 3 cohorts: ropivacaine 0.2% 5–8 mL/hour continuous wound infusion, 10 mL programmed intermittent bolus 2 hourly, 20 mL programmed intermittent bolus 4 hourly. The primary outcome was the maximum daily Numerical Rating Pain Score with movement (dynamic pain score) recorded during first 96 hours postprocedure. Secondary outcomes included the maximum daily resting pain score and opioid utilization.ResultsIn three cohorts of 70 patients (n=210), the maximum daily dynamic pain score in the intermittent bolus 2-hourly and 4-hourly cohorts was lower when compared with the continuous infusion group over the first 4 postoperative days. The mean difference in maximum daily pain score with respect to the continuous infusion regime was 0.8 (95% CI 0.2 to 1.4) for the intermittent bolus 2-hourly group and 0.6 (95% CI 0.0 to 1.2) for the 4-hourly group. Generalized estimating equation modeling indicates the reduction in dynamic pain score is greatest with the intermittent bolus 2-hourly regime over the first 72 hours postprocedure. The 2-hourly intermittent bolus regime was also associated with lower opioid utilization and local anesthetic exposure.ConclusionsIntermittent wound infusion catheter infusion regimes were associated with lower maximum daily dynamic pain scores, although the magnitude of this change may be of limited clinical significance.
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20
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Dhanekula ND, Crouch G, Byth K, Lau SL, Kim A, Graham E, Ellis A, Clifton‐Bligh RJ, Girgis CM. Asian Ethnicity and Femoral Geometry in Atypical Femur Fractures: Independent or inter‐dependent risk factors? JBMR Plus 2022; 6:e10607. [PMID: 35434447 PMCID: PMC9009102 DOI: 10.1002/jbm4.10607] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 11/11/2022] Open
Abstract
The earliest reports of atypical femur fractures (AFF) emerged from Asia. In the West, epidemiologic studies report a greater incidence of AFFs among subjects of Asian background. Asian ethnicity is an established risk factor for AFF, but clear mechanisms to explain this risk and implications for the general development of AFF are open questions. Ethno‐specific differences in bisphosphonate action and femoral geometry have been proposed as hypotheses. In a retrospective cohort of 163 female patients presenting with AFFs or typical femur fractures (TFF), relative contributions of Asian ethnicity, proximal femoral geometry, and bisphosphonate use in AFF status were examined. There was a fourfold higher proportion of Asian subjects in the AFF compared with TFF groups (31.6%, 30/95 versus 7.4%, 5/68). Asian subjects had smaller femurs in femoral head, neck, and axial dimensions. A multiple logistic regression model for AFF status was fitted adding Asian ethnicity to three previously reported independent predictors of AFF including femoral geometry, which together comprise the Sydney AFF Score (age ≤80 years, femoral neck width <37 mm than non‐Asian, lateral cortical width at lesser trochanter ≥5 mm). Asian ethnicity was a robust independent predictor of AFF, imparting sevenfold increase in the odds of AFF after adjusting for all three variables (95% confidence interval [CI] 2.2–23.2, p = 0.001) or for overall AFF score (95% CI 2.2–22.3 p = 0.001). Overall Asian subjects had higher rates of bisphosphonate use than non‐Asian subjects (67.6% versus 47.2%, p = 0.034). Among AFF bisphosphonate users, Asian subjects had lower AFF scores than non‐Asians (Sydney AFF Score ≤1, 45.5% Asian subjects versus 22.2% non‐Asian subjects, p = 0.05). Asian ethnicity is a strong independent risk factor for AFF, unaccounted for by ethno‐specific differences in proximal femoral geometry. Bisphosphonate use may be associated with a greater predisposition for AFF in Asian subjects compared with non‐Asian subjects. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Nitesh D Dhanekula
- Faculty of Medicine and Health University of Sydney Sydney NSW Australia
- Department of Orthopaedic Surgery Westmead Hospital Westmead NSW Australia
| | - Gareth Crouch
- Faculty of Medicine and Health University of Sydney Sydney NSW Australia
| | - Karen Byth
- Faculty of Medicine and Health University of Sydney Sydney NSW Australia
- Western Sydney Local Health District (WSLHD) Research and Education Network, Westmead Hospital Westmead NSW Australia
| | - Sue Lynn Lau
- Faculty of Medicine and Health University of Sydney Sydney NSW Australia
- Department of Diabetes and Endocrinology Westmead Hospital Westmead NSW Australia
| | - Albert Kim
- Faculty of Medicine and Health University of Sydney Sydney NSW Australia
- Department of Diabetes and Endocrinology Westmead Hospital Westmead NSW Australia
- Department of Endocrinology and Diabetes Royal North Shore Hospital St Leonards NSW Australia
| | - Edward Graham
- Department of Orthopaedic Surgery Westmead Hospital Westmead NSW Australia
| | - Andrew Ellis
- Department of Orthopaedic Surgery Royal North Shore Hospital St Leonards NSW Australia
| | - Roderick J Clifton‐Bligh
- Faculty of Medicine and Health University of Sydney Sydney NSW Australia
- Department of Endocrinology and Diabetes Royal North Shore Hospital St Leonards NSW Australia
- Kolling Institute of Medical Research Sydney NSW Australia
| | - Christian M Girgis
- Faculty of Medicine and Health University of Sydney Sydney NSW Australia
- Department of Diabetes and Endocrinology Westmead Hospital Westmead NSW Australia
- Department of Endocrinology and Diabetes Royal North Shore Hospital St Leonards NSW Australia
- The Westmead Institute for Medical Research Westmead NSW Australia
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21
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Trivedi S, Stefani L, Byth K, Brown P, Qian P, Kumar S, Thomas S, Thomas L. Left Ventricular Diastolic Dysfunction and Left Atrial Myopathy Independently Predict Atrial Fibrillation Recurrence Post Pulmonary Vein Isolation. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.026] [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: 11/29/2022]
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22
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Al-Omary A, Byth K, Weltman M, George J, Eslam M. The importance and impact of recognizing metabolic dysfunction-associated fatty liver disease in patients with chronic hepatitis C. J Dig Dis 2022; 23:33-43. [PMID: 34902220 DOI: 10.1111/1751-2980.13071] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 11/20/2021] [Accepted: 12/08/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Metabolic dysfunction-associated fatty liver disease (MAFLD) can develop in any patient, including those with chronic hepatitis C (CHC). The recently proposed diagnostic criteria for MAFLD provide a unique opportunity to investigate the impact of concomitant fatty liver in patients with another established cause for their liver disease. The objective of our study was to assess the characteristics and outcomes of patients with a dual etiology liver disease. METHODS We evaluated 1181 patients including 744 with CHC and 437 with MAFLD. All patients in both cohorts underwent liver biopsy indicating disease activity and fibrosis stage. RESULTS Nearly half (43.1%) the patients with CHC had concomitant MAFLD. Comparing patients with CHC alone with those with a dual etiology disease, we found that the latter had more severe liver injury, hepatic inflammation and fibrosis (all P < 0.001). Interestingly, lean or normal-weight patients with CHC and MAFLD had a similar fibrosis stage compared to the two other subgroups of MAFLD (obesity and/or diabetes mellitus). There was no statistical significance in hepatic steatosis and fibrosis between genotype 3 CHC and MAFLD group compared to other genotypes. CONCLUSIONS Patients with CHC and concomitant MAFLD had more severe liver disease than those with viral hepatitis alone. Recognizing coexisting MAFLD in patients with CHC is important for the delivery of holistic care.
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Affiliation(s)
- Ahmed Al-Omary
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia.,Nepean Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Martin Weltman
- Nepean Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Mohammed Eslam
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
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23
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Trivedi S, Stefani L, Byth K, Brown P, Qian P, Kumar S, Thomas S, Thomas L. Medium-term Maintenance of Sinus Rhythm Post Pulmonary Vein Isolation Results in Significant Cardiac Reverse Remodelling. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.175] [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: 11/29/2022]
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24
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Gupta S, Sidhu M, Shahidi N, Vosko S, McKay O, Zahid S, Whitfield A, Byth K, Brown G, Lee EYT, Williams SJ, Burgess NG, Bourke MJ. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2021; 7:152-160. [PMID: 34801133 DOI: 10.1016/s2468-1253(21)00384-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is a cornerstone in the management of large (≥20 mm) non-pedunculated colorectal polyps. Clinically significant post-EMR bleeding occurs in 7% of cases and is most frequently encountered in the right colon. We aimed to assess the use of prophylactic clip closure in preventing clinically significant post-EMR bleeding within the right colon. METHODS We conducted a randomised controlled trial at a tertiary centre in Australia. Patients referred for the EMR of large non-pedunculated colorectal polyps in the right colon were eligible. Patients were randomly assigned (1:1) into the clip or control (no clip) group, using a computerised random-number generator. The primary endpoint was clinically significant post-EMR bleeding, defined as haematochezia necessitating emergency department presentation, hospitalisation, or re-intervention within 14 days post-EMR, which was analysed on the basis of intention-to-treat principles. The trial is registered with ClinicalTrials.gov, NCT02196649, and has been completed. FINDINGS Between Feb 4, 2016, and Dec 15, 2020, 231 patients were randomly assigned: 118 to the clip group and 113 to the control group. In the intention-to-treat analysis, clinically significant post-EMR bleeding was less frequent in the clip group than in the control group (four [3·4%] of 118 patients vs 12 [10·6%] of 113; p=0·031; absolute risk reduction 7·2% [95% CI 0·7-13·8]; number needed to treat 13·9). There were no differences between groups in adverse events, including delayed perforation (one [<1%] in the clip group vs one [<1%] in the control group) and post-EMR pain (four [3%] vs six [5%]). No deaths were reported. INTERPRETATION Prophylactic clip closure can be performed following the EMR of large non-pedunculated colorectal polyps of 20 mm or larger in the right colon to reduce the risk of clinically significant post-EMR bleeding. FUNDING None.
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Karen Byth
- Western Sydney Local Health District Research and Education Network, Westmead Hospital, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, VIC, Australia
| | - Eric Yong Tat Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Stephen John Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Nicholas Graeme Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Michael John Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
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Vosko S, Shahidi N, Sidhu M, van Hattem WA, Bar-Yishay I, Schoeman S, Tate DJ, Hourigan LF, Singh R, Moss A, Byth K, Lee EYT, Burgess NG, Bourke MJ. Optical Evaluation for Predicting Cancer in Large Nonpedunculated Colorectal Polyps Is Accurate for Flat Lesions. Clin Gastroenterol Hepatol 2021; 19:2425-2434.e4. [PMID: 33992780 DOI: 10.1016/j.cgh.2021.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The ability of optical evaluation to diagnose submucosal invasive cancer (SMIC) prior to endoscopic resection of large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) is critical to inform therapeutic decisions. Prior studies suggest that it is insufficiently accurate to detect SMIC. It is unknown whether lesion morphology influences optical evaluation performance. METHODS LNPCPs ≥20 mm referred for endoscopic resection within a prospective, multicenter, observational cohort were evaluated. Optical evaluation was performed prior to endoscopic resection with the optical prediction of SMIC based on established features (Kudo V pit pattern, depressed morphology, rigidity/fixation, ulceration). Optical evaluation performance outcomes were calculated. Outcomes were reported by dominant morphology: nodular (Paris 0-Is/0-IIa+Is) vs flat (Paris 0-IIa/0-IIb) morphology. RESULTS From July 2013 to July 2019, 1583 LNPCPs (median size 35 [interquartile range, 25-50] mm; 855 flat, 728 nodular) were assessed. SMIC was identified in 146 (9.2%; 95% confidence interval [CI], 7.9%-10.8%). Overall sensitivity and specificity were 67.1% (95% CI, 59.2%-74.2%) and 95.1% (95% CI, 93.9%-96.1%), respectively. The overall SMIC miss rate was 3.0% (95% CI, 2.3%-4.0%). Significant differences in sensitivity (90.9% vs 52.7%), specificity (96.3% vs 93.7%), and SMIC miss rate (0.6% vs 5.9%) between flat and nodular LNPCPs were identified (all P < .027). Multiple logistic regression identified size ≥40 mm (odds ratio [OR], 2.0; 95% CI, 1.0-3.8), rectosigmoid location (OR, 2.0; 95% CI, 1.1-3.7), and nodular morphology (OR, 7.2; 95% CI, 2.8-18.9) as predictors of missed SMIC (all P < .039). CONCLUSIONS Optical evaluation performance is dependent on lesion morphology. In the absence of features suggestive of SMIC, flat lesions can be presumed benign and be managed accordingly.
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Affiliation(s)
- Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, School of Medicine University of Queensland, Brisbane, Queensland, Australia; Department of Gastroenterology, Greenslopes Private Hospital, Gallipoli Medical Research Foundation, Brisbane, Queensland, Australia
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Lyell McEwan Hospital, Adelaide, South Australia, Australia
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Victoria, Australia
| | - Karen Byth
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; WSLHD Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
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26
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Vosko S, Gupta S, Shahidi N, van Hattem WA, Zahid S, McKay O, Whitfield A, Sidhu M, Tate DJ, Lee EYT, Byth K, Williams SJ, Burgess N, Bourke MJ. Impact of technical innovations in EMR in the treatment of large nonpedunculated polyps involving the ileocecal valve (with video). Gastrointest Endosc 2021; 94:959-968.e2. [PMID: 33989645 DOI: 10.1016/j.gie.2021.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 05/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The endoscopic management of large nonpedunculated colorectal polyps involving the ileocecal valve (ICV-LNPCPs) remains challenging because of its unique anatomic features, with long-term outcomes inferior to LNPCPs not involving the ICV. We sought to evaluate the impact of technical innovations and advances in the EMR of ICV-LNPCPs. METHODS The performance of EMR for ICV-LNPCPs was retrospectively evaluated in a prospective observational cohort of LNPCPs ≥20 mm. Efficacy was measured by clinical success (removal of all polypoid tissue during index EMR and avoidance of surgery) and recurrence at first surveillance colonoscopy. Accounting for the adoption of technical innovations, comparisons were made between an historical cohort (September 2008 to April 2016) and contemporary cohort (May 2016 to October 2020). Safety was evaluated by documenting the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury, and delayed perforation. RESULTS Between September 2008 to October 2020, 142 ICV-LNPCPs were referred for EMR. Median ICV-LNPCP size was 35 mm (interquartile range, 25-50 mm). When comparing the contemporary (n = 66) and historical cohorts (n = 76) of ICV-LNPCPs, there were significant differences in clinical success (93.9% vs 77.6%, P = .006) and recurrence (4.6% vs 21.0%, P = .019). CONCLUSIONS With technical advances, ICV-LNPCPs can be effectively and safely managed by EMR, independent of lesion complexity. Most patients experience excellent outcomes and avoid surgery.
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Affiliation(s)
- Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | | | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; WSLHD Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Liu Y, Evans L, Kwan T, Callister J, Poon S, Byth K, Harnett P. Developing a maturity model for cancer multidisciplinary teams. Int J Med Inform 2021; 156:104610. [PMID: 34649110 DOI: 10.1016/j.ijmedinf.2021.104610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/26/2021] [Revised: 09/11/2021] [Accepted: 09/30/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Multidisciplinary teams (MDTs) are considered the "gold standard" of care for patients with cancer but how well they function and the role they play in decision making varies widely. Although several observational tools have been developed to evaluate MDT performance, they are resource intensive and only assess MDT performance at a static point in time. The aim of this study was to develop a validated maturity model as a self-assessment instrument for MDTs to evaluate their performance and monitor improvement over time. METHODS The authors used a three-phase methodology to develop a maturity model. In the first phase, using a modified Delphi technique, we identified 20 indicators (within five components), each having five levels of maturity [1]. In the second phase, further Delphi iterations were undertaken to refine the content and structure of the model. By the end of the second phase six components and 17 indicators had been established. In the third phase, the refined model was distributed to members from 11 MDTs to test for validity and reliability. 101 valid responses were received. Principal Component Analysis was used to determine the optimal number of components that fit the indicators. Factors with eigenvalue greater than one were extracted. Cronbach's alpha (α) was used to measure the internal consistency of components. Bivariate correlation analysis, measuring pair-wise relationships between indicators (r), was undertaken to assess convergent and discriminant validity. RESULTS Five factors were extracted from Principal Component Analysis. For the factors extracted, 16 out of 17 indicators showed loadings greater than the 0.4 threshold. All components demonstrated good levels of internal consistency (α > 0.8) and convergent validity (r > 0.6). Discriminant validity cannot be established. Ratings for ease of use (3.6/5) and usefulness (3.4/5) were considered acceptable. CONCLUSIONS Further work is required to establish discriminant validity and refine the components and indicators. Once further refinement and validation are completed, the maturity model should be a simple tool for MDTs to measure their performance and monitor improvement over time.
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Affiliation(s)
- Yiren Liu
- Western Sydney Local Health District, Westmead NSW 2145, Australia.
| | - Lynleigh Evans
- Sydney West Translational Cancer Research Centre, Western Sydney Local Health District, Westmead NSW 2145, Australia; Western Sydney Local Health District, Westmead NSW 2145, Australia.
| | - Terence Kwan
- Faculty of Engineering, The University of Sydney, Camperdown, NSW 2006, Australia
| | - James Callister
- Faculty of Engineering, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Simon Poon
- Faculty of Engineering, The University of Sydney, Camperdown, NSW 2006, Australia.
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead NSW 2145, Australia.
| | - Paul Harnett
- Sydney West Translational Cancer Research Centre, Western Sydney Local Health District, Westmead NSW 2145, Australia; Western Sydney Local Health District, Westmead NSW 2145, Australia.
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van Hattem WA, Shahidi N, Vosko S, Hartley I, Britto K, Sidhu M, Bar-Yishay I, Schoeman S, Tate DJ, Byth K, Hewett DG, Pellisé M, Hourigan LF, Moss A, Tutticci N, Bourke MJ. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70:1691-1697. [PMID: 33172927 DOI: 10.1136/gutjnl-2020-321753] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Large (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known. DESIGN Consecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods. RESULTS A total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively. CONCLUSIONS In a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.
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Affiliation(s)
- W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kaushali Britto
- Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David James Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium
| | - Karen Byth
- Biostatistics, Sydney University, Sydney, New South Wales, Australia
| | - David G Hewett
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Division of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - María Pellisé
- Gastroenterology, Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Luke F Hourigan
- Department of gastroenterology and hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia.,Department of gastroenterology and hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Alan Moss
- Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nicholas Tutticci
- Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia .,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Baguley IJ, Barden HL, Byth K. Investigating Inducible Muscle Overactivity in Acquired Brain Injury and the Impact of Botulinum Toxin A. Arch Phys Med Rehabil 2021; 103:75-82.e1. [PMID: 34416250 DOI: 10.1016/j.apmr.2021.07.802] [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: 03/25/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the pattern of change in muscle overactivity during repetitive grasp/release using dynamic computerized dynamometry (DCD; objective 1) and the effect of botulinum toxin A (BTX-A; objective 2). DESIGN Secondary analysis of an observational cohort study. SETTING Hospital outpatient spasticity management service. PARTICIPANTS A convenience sample (N=65), comprising adults with upper motor neuron syndrome affecting the arm after acquired brain injury (ABI; n=38) and participants without ABI (n=27). INTERVENTIONS After clinical assessment, a subgroup of participants with ABI (n=28) underwent BTX-A injections as part of their spasticity management. MAIN OUTCOME MEASURES Post hoc DCD data processing extracted the values of minimum force generation between 10 sequential contractions. The pattern of change was analyzed. RESULTS The ABI injected group exerted greater force at baseline than both other groups (ABI injected=1.04 kg, ABI noninjected=0.74 kg, participants without ABI=0.53 kg; P=.011). After the first contraction, minimum force values increased for all groups and were greatest in the ABI injected group. With subsequent cycles, the group without ABI showed a linear pattern of decreasing force generation, whereas both ABI groups showed a quadratic increasing pattern, which was of greater magnitude in the ABI injected group. After injection, values for the ABI injected group showed a 51% reduction in inducible muscle overactivity (P=.003) to magnitudes similar to those of the ABI noninjected group. CONCLUSIONS This study showed that hand relaxation deteriorated during repetitive movements in people with spasticity, a feature hypothesized to adversely influence everyday hand function. After BTX-A injection, the magnitude but not the pattern of this inducible muscle overactivity improved.
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Affiliation(s)
- Ian J Baguley
- From the Brain injury Rehabilitation Service, Westmead Hospital, Wentworthville; The University of Sydney School of Medicine, Sydney.
| | - Hannah L Barden
- From the Brain injury Rehabilitation Service, Westmead Hospital, Wentworthville; Discipline of Occupational Therapy, Sydney School of Health Sciences, Faculty of Medicine and Health, the University of Sydney, Sydney
| | - Karen Byth
- Research and Education Network, Westmead Hospital, Wentworthville; NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
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Bradbury RA, Christie-David D, Smith HC, Byth K, Eastman CJ. Prior iodine exposure and impact on thyroid function during controlled ovarian hyperstimulation: A prospective study. Aust N Z J Obstet Gynaecol 2021; 62:133-139. [PMID: 34406645 DOI: 10.1111/ajo.13419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 05/18/2021] [Accepted: 07/20/2021] [Indexed: 11/28/2022]
Abstract
AIMS Iodine supplements are recommended for women planning pregnancy, but their impact on thyroid function during controlled ovarian hyperstimulation (COH) and into pregnancy is unknown. The aim of this study was to assess the impact of iodine supplementation on thyroid function during COH. METHODS One-hundred and six euthyroid women (thyroid stimulating hormone (TSH) 0.4-2.5 mIU/L) planning their first COH cycle were subdivided according to iodine supplementation (nil, <6 months, ≥6 months) and compared to levothyroxine (LT4)-treated controls. Serial TSH, free thyroxine, free triiodothyronine and thyroglobulin (Tg) levels were recorded at four time points: (i) baseline, (ii) day 7 ovarian stimulation, (iii) ovulation trigger and (iv) two weeks post oocyte retrieval. Oocyte numbers, fertilisation rates and pregnancy outcome were recorded. RESULTS TSH increased during COH for those women taking iodine supplements for ≥6 months (P = 0.025). One quarter recorded a TSH level >2.5 mIU/L before embryo transfer. A similar increase in TSH was demonstrated by LT4-dependent controls (P = 0.024) but not the remaining subgroups. Tg levels did not change during COH in any group but decreased significantly post oocyte retrieval if nil iodine (P < 0.0001) or supplemented for ≥6 months (P < 0.005). Iodine supplementation did not influence oocyte count, fertilisation or implantation rates. Women taking iodine for <6 months were four times more likely to achieve a live birth than women taking iodine for longer. CONCLUSIONS Women taking iodine supplements for ≥6 months are less able to adapt to the thyroidal demands of COH, with responses comparable to LT4-dependent patients.
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Affiliation(s)
- Rachel A Bradbury
- Westmead Fertility Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Darshika Christie-David
- University of Sydney, Sydney, New South Wales, Australia.,Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Howard C Smith
- Westmead Fertility Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Karen Byth
- Western Sydney Local Health District (WSLHD) Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia.,National Health and Medical Research Council (NHMRC) Clinical Trial Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Creswell J Eastman
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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Rao A, Zecchin R, Byth K, Denniss AR, Hickman LD, DiGiacomo M, Phillips JL, Newton PJ. The Role of Lifestyle and Cardiovascular Risk Factors in Dropout From an Australian Cardiac Rehabilitation Program. A Longitudinal Cohort Study. Heart Lung Circ 2021; 30:1891-1900. [PMID: 34219025 DOI: 10.1016/j.hlc.2021.05.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Received: 11/10/2020] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cardiac rehabilitation (CR) programs reduce the risk of further cardiac events and improve the ability of people living with cardiovascular disease to manage their symptoms. However, many people who experience a cardiac event do not attend or fail to complete their CR program. Little is known about the characteristics of people who drop out compared to those who complete CR. AIMS To identify subgroups of patients attending a cardiac rehabilitation program who are more likely to dropout prior to final assessment by (1) calculating the dropout rate from the program, (2) quantifying the association between dropout and socio-demographic, lifestyle, and cardiovascular risk factors, and (3) identifying independent predictors of dropout. METHODS The study population is from a large metropolitan teaching hospital in Sydney, Australia, and consists of all participants consecutively enrolled in an outpatient CR program between 2006 and 2017. Items assessed included diagnoses and co-morbidities, quality of life (SF-36), psychological health (DASS-21), lifestyle factors and physical assessment. Dropout was defined as failure to complete the outpatient CR program and post CR assessment. RESULTS Of the 3,350 patients enrolled in the CR program, 784 (23.4%; 95%CI: 22.0-24.9%) dropped out prior to completion. The independent predictors of dropout were smoking (OR 2.4; 95%CI: 1.9-3.0), being separated or divorced (OR 2.0; 95%CI: 1.5-2.6), younger age (<55 years) (OR 1.9; 95%CI: 1.6-2.4), obesity (OR 1.6; 95%CI: 1.3-2.0), diabetes (OR 1.6; 95%CI: 1.3-2.0), sedentary lifestyle (OR 1.3; 95%CI: 1.1-1.6) and depressive symptoms (OR 1.3; 95%CI: 1.1-1.6). CONCLUSION To improve the CR program completion rate, clinicians need to consider the impact of socio-demographic, lifestyle, and cardiovascular risk factors on their patients' ability to complete CR. Tailored strategies which target the independent predictors of dropout are required to promote adherence to CR programs and thereby potentially reduce long-term cardiovascular risk.
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Affiliation(s)
- Angela Rao
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia; Calvary Hospital, South Eastern Sydney Local Health District, Sydney, NSW, Australia.
| | - Robert Zecchin
- Western Sydney Local Health District, Sydney, NSW, Australia
| | - Karen Byth
- Western Sydney Local Health District, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia
| | - A Robert Denniss
- Western Sydney Local Health District, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia; Western Sydney University, Sydney, NSW, Australia
| | - Louise D Hickman
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Michelle DiGiacomo
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Jane L Phillips
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
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Bennett R, Campbell T, Byth K, Turnbull S, Kumar S. Catheter Ablation Using Half-Normal Saline and Dextrose Irrigation in an Ovine Ventricular Model. JACC Clin Electrophysiol 2021; 7:1229-1239. [PMID: 34217664 DOI: 10.1016/j.jacep.2021.05.002] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 04/27/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study hypothesized that catheter ablation in healthy ovine ventricular myocardium using low ionic 0.45% saline (half-normal saline [HNS]) and nonionic 5% dextrose in water (D5W) would result in larger lesions compared with use of 0.9% saline (normal saline [NS]). BACKGROUND Limited data exist regarding the safety and efficacy of catheter ablation using low and nonionic irrigants. METHODS Open irrigated ablation was performed on 14 beating ovine hearts (NS, n = 5; HNS, n = 4; D5W, n = 5). Ablation was delivered by using identical parameters (ie, 30 W in power control mode, 60-second duration, contact force of 10-20 g in the endocardial ventricles and 5-10 g in the epicardium). Catheter orientation and tissue contact were optimized by using intracardiac echocardiography. Lesion width, depth, and volume and number of steam pops were compared. RESULTS Overall, 196 lesions were analyzed (mean duration: 56.7 ± 8.3 seconds; mean contact force: 15.3 ± 6.1 g; and mean impedance drop: 31 ± 19.1 Ω). Compared with NS, HNS and D5W resulted in larger lesion volumes (NS 349.2 ± 245.1 mm3 vs HNS 645.7 ± 386.4 mm3 vs D5W 633.2 ± 387.1 mm3; HNS vs NS, P < 0.001; D5W vs NS, P < 0.001; D5W vs HNS, P = 0.87). However, D5W was associated with higher steam pop occurrence (NS 5% vs HNS 11% vs D5W 35%; HNS vs NS, P = 0.22; D5W vs NS, P < 0.001; D5W vs HNS, P = 0.002). CONCLUSIONS Catheter ablation with HNS and D5W resulted in larger ablation lesions compared with NS but similar lesion dimensions between HNS and D5W. The increase in lesion size with HNS and D5W was associated with a higher incidence of steam pops, especially with D5W, compared with NS.
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Affiliation(s)
- Richard Bennett
- Department of Cardiology, University of Sydney, Westmead Hospital, Sydney, New South Wales, Australia
| | - Timothy Campbell
- Department of Cardiology, University of Sydney, Westmead Hospital, Sydney, New South Wales, Australia
| | - Karen Byth
- Department of Cardiology, University of Sydney, Westmead Hospital, Sydney, New South Wales, Australia
| | - Samual Turnbull
- Department of Cardiology, University of Sydney, Westmead Hospital, Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Department of Cardiology, University of Sydney, Westmead Hospital, Sydney, New South Wales, Australia.
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Ubrihien A, Stone AC, Byth K, Davies SC. The impact of Grindr advertising on attendance and HIV testing by men who have sex with men at a sexual health clinic in northern Sydney. Int J STD AIDS 2021; 31:989-995. [PMID: 32772689 DOI: 10.1177/0956462420927815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/15/2022]
Abstract
Grindr is a geolocation smartphone application popular among men who have sex with men (MSM) to find sexual partners. We conducted a study to assess if attendance and HIV testing amongst MSM increased due to advertisements on Grindr that promoted our service. We measured clinic website hits by users clicking through from Grindr; we counted self-reported registrations that nominated referral from Grindr; and we compared new patient attendances and HIV tests in MSM with heterosexual men, for the 18 months preceding the intervention and the 18 months of the intervention. During the intervention the clinic's website received 11,799 unique hits from Grindr users. The average monthly rate of attendances by new MSM increased 70.3% from 19.0 to 32.3, compared with a 5.5% increase among new heterosexual men from 45.6 to 48.1. The average monthly rate of HIV tests among MSM increased 43.6% from 47.0 to 67.6, compared with a 3.9% increase amongst heterosexual men from 40.0 to 41.6. The MSM:heterosexual men rate ratio for new patient attendances changed from 0.42 to 0.67 (p < 0.001, adjusted for possible underlying time trends in each period), and for HIV tests this rate ratio changed from 1.18 to 1.63 (p < 0.001, adjusted for possible underlying time trends in each period). The effects of the intervention did not significantly change over the course of the 18-month intervention. This study suggests that advertising on Grindr was effective and durable as a means of increasing attendance and HIV testing rates among MSM in northern Sydney.
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Affiliation(s)
- Ashley Ubrihien
- HIV and Related Program Unit, Northern Sydney Sexual Health Service, Sydney, Australia
| | - Andrew C Stone
- HIV and Related Program Unit, Northern Sydney Sexual Health Service, Sydney, Australia
| | - Karen Byth
- WSLHD Research and Education Network, Westmead Hospital, Sydney, Australia
| | - Stephen C Davies
- Northern Sydney Sexual Health Service, Northern Sydney Local Health District, Sydney, Australia.,Northern Clinical School, University of Sydney, Sydney, Australia
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Lambeth C, Perri R, Lee S, Verma M, Campbell-Rogers N, Larcos G, Byth K, Kairaitis K, Amis T, Wheatley J. Predictors for carotid and femoral artery intima-media thickness in a non-diabetic sleep clinic cohort. PLoS One 2021; 16:e0252569. [PMID: 34086802 PMCID: PMC8177540 DOI: 10.1371/journal.pone.0252569] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 05/15/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction The impact of sleep disordered breathing (SDB) on arterial intima-media thickness (IMT), a surrogate measure for cardiovascular disease, remains uncertain, in part because of the potential for non-SDB vascular risk factor interactions. In the present study, we determined predictors for common carotid (CCA) and femoral (CFA) artery IMT in an adult, sleep clinic cohort where non-SDB vascular risk factors (particularly diabetes) were eliminated or controlled. Methods We recruited 296 participants for polysomnography (standard SDB severity metrics) and CCA/CFA ultrasound examinations, followed by a 12 month vascular risk factor minimisation (RFM) and continuous positive pressure (CPAP) intervention for participants with a range of SDB severity (RFM Sub-Group, n = 157; apnea hyponea index [AHI]: 14.7 (7.2–33.2), median [IQR]). Univariable and multivariable linear regression models determined independent predictors for IMT. Linear mixed effects modelling determined independent predictors for IMT change across the intervention study. P<0.05 was considered significant. Results Age, systolic blood pressure and waist:hip ratio were identified as non-SDB predictive factors for CCA IMT and age, weight and total cholesterol:HDL ratio for CFA IMT. No SDB severity metric emerged as an independent predictor for either CCA or CFA IMT, except in the RFM Sub-Group, where a 2-fold increase in AHI predicted a 2.4% increase in CFA IMT. Across the intervention study, CCA IMT decreased in those who lost weight, but there was no CPAP use interaction. CFA IMT, however, decreased by 12.9% (95%CI 6.8, 18.7%, p = 0.001) in those participants who both lost weight and used CPAP > = 4hours/night. Conclusion We conclude that SDB severity has little impact on CCA IMT values when non-SDB vascular risk factors are minimised or not present. This is the first study, however, to suggest a potential linkage between SDB severity and CFA IMT values. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12611000250932 and ACTRN12620000694910.
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Affiliation(s)
- Christopher Lambeth
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Westmead, Sydney, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Rita Perri
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Westmead, Sydney, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Sharon Lee
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Westmead, Sydney, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Manisha Verma
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Westmead, Sydney, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Nicole Campbell-Rogers
- Department of Nuclear Medicine and Ultrasound, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - George Larcos
- Department of Nuclear Medicine and Ultrasound, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Kristina Kairaitis
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Westmead, Sydney, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Terence Amis
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Westmead, Sydney, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- * E-mail:
| | - John Wheatley
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Westmead, Sydney, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Crouch G, Dhanekula ND, Byth K, Burn E, Lau SL, Nairn L, Nery L, Doyle J, Graham E, Ellis A, Clifton-Bligh RJ, Girgis CM. The Sydney AFF Score: A Simple Tool to Distinguish Females Presenting With Atypical Femur Fractures Versus Typical Femur Fractures. J Bone Miner Res 2021; 36:910-920. [PMID: 33528853 DOI: 10.1002/jbmr.4255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 01/05/2021] [Accepted: 01/12/2021] [Indexed: 01/21/2023]
Abstract
Atypical femur fractures (AFF) are a rare but serious complication of long-term bisphosphonate use. Although clearly defined by ASBMR criteria, a proportion of patients with AFFs may go unrecognized and the use of qualitative fracture criteria may lead to uncertainty in AFF diagnosis, with significant therapeutic implications. A score that rapidly and accurately identifies AFFs among subtrochanteric femur fractures using quantitative, measurable parameters is needed. In a retrospective cohort of 110 female patients presenting with AFFs or typical femur fractures (TFFs), multiple logistic regression and decision tree analysis were used to develop the Sydney AFF score. This score, based on demographic and femoral geometry variables, uses three dichotomized independent predictors and adds one point for each: (age ≤80 years) + (femoral neck width <37 mm) + (lateral cortical width at lesser trochanter ≥5 mm), (score, 0 to 3). In an independent validation set of 53 female patients at a different centre in Sydney, a score ≥2 demonstrated 73.3% sensitivity and 69.6% specificity for AFF (area under the receiver-operating characteristic curve [AUC] 0.775, SE 0.063) and remained independently associated with AFF after adjustment for bisphosphonate use. The Sydney AFF score provides a quantitative means of flagging female patients with atraumatic femur fractures who have sustained an AFF as opposed to a TFF. This distinction has clear management implications and may augment current ASBMR diagnostic criteria. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Gareth Crouch
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nitesh D Dhanekula
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Department of Orthopaedic Surgery, Westmead Hospital, Westmead, NSW, Australia
| | - Karen Byth
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Western Sydney Local Health District (WSLHD) Research and Education Network, Westmead Hospital, Westmead, NSW, Australia
| | - Emma Burn
- Department of Medicine, West Suffolk Hospital, Bury St Edmonds, UK
| | - Sue Lynn Lau
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Department of Endocrinology and Diabetes, Westmead Hospital, Westmead, NSW, Australia
| | - Lillias Nairn
- Department of Physiotherapy, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Liza Nery
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Jean Doyle
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Edward Graham
- Department of Orthopaedic Surgery, Westmead Hospital, Westmead, NSW, Australia
| | - Andrew Ellis
- Department of Orthopaedic Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Roderick J Clifton-Bligh
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, Australia.,Kolling Institute of Medical Research, Sydney, NSW, Australia
| | - Christian M Girgis
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Department of Endocrinology and Diabetes, Westmead Hospital, Westmead, NSW, Australia.,Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, NSW, Australia.,The Westmead Institute for Medical Research, Westmead, NSW, Australia
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36
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Coggins AR, Vivekanandamoorthy N, Byth K, Aleemullah T, Selvendran ST, Watkins RJ, Shetty AL, Devjak L, Hsu JM. Utility of venous blood gases for the assessment of traumatic shock: a prospective observational study. Emerg Med J 2021; 38:711-717. [PMID: 33789938 DOI: 10.1136/emermed-2020-209751] [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: 04/09/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND ABG samples are often obtained in trauma patients to assess shock severity. Venous blood gas (VBG) sampling, which is less invasive, has been widely used to assess other forms of shock. The study aim was to determine the agreement between VBG and ABG measurements in trauma. METHODS Patients were enrolled at an Australian trauma centre between October 2016 and October 2018. Bland-Altman limits of agreement (LOA) between paired blood gas samples taken <30 min apart were used to quantify the extent of agreement. The impact of using only VBG measurements was considered using an a priori plan. Cases where venous sampling failed to detect 'concerning levels' were flagged using evidence-based cut-offs: pH ≤7.2, base deficit (BD) ≤-6, bicarbonate <21 and lactate ≥4. Case summaries of these patients were assessed by independent trauma clinicians as to whether an ABG would change expected management. RESULTS During the study period 176 major trauma patients had valid paired blood gas samples available for analysis. The median time difference between paired measurements was 11 min (IQR 6-17). There was a predominance of men (81.8%) and blunt trauma (92.0%). Median Injury Severity Score was 13 (range 1-75) and inpatient mortality was 6.3%. Mean difference (ABG-VBG) and LOA between paired arterial and venous measurements were 0.036 (LOA -0.048 to 0.120) for pH, -1.27 mmol/L (LOA -4.35 to 1.81) for BD, -0.64 mmol/L (LOA -1.86 to 0.57) for lactate and -1.97 mmol/L (LOA -5.49 to 1.55) for bicarbonate. Independent assessment of the VBG 'false negative' cases (n=20) suggested an ABG would change circulatory management in two cases. CONCLUSIONS In trauma patients VBG and ABG parameters displayed suboptimal agreement. However, in cases flagged as VBG 'false negative' independent review indicated that the availability of an ABG was unlikely to change management.
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Affiliation(s)
- Andrew R Coggins
- Emergency Medicine, Westmead Hospital, Westmead, New South Wales, Australia .,Discipline of Emergency Medicine, The University of Sydney Westmead Clinical School, Sydney, New South Wales, Australia
| | | | - Karen Byth
- Biostatistics Department, NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Tabish Aleemullah
- Department of Trauma, Westmead Hospital, Westmead, New South Wales, Australia
| | - Selwyn T Selvendran
- Department of Trauma, Westmead Hospital, Westmead, New South Wales, Australia
| | - Rachel J Watkins
- Department of Trauma, Westmead Hospital, Westmead, New South Wales, Australia
| | - Amith L Shetty
- Discipline of Emergency Medicine, The University of Sydney Westmead Clinical School, Sydney, New South Wales, Australia
| | - Lorraine Devjak
- Nursing Resources, Westmead Hospital, Westmead, New South Wales, Australia
| | - Jeremy M Hsu
- Department of Trauma, Westmead Hospital, Westmead, New South Wales, Australia.,Discipline of Surgery, The University of Sydney Westmead Clinical School, Sydney, New South Wales, Australia
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Trivedi SJ, Tang S, Byth K, Stefani L, Lo Q, Otton J, Jameson M, Tran D, Batumalai V, Holloway L, Delaney GP, Koh ES, Thomas L. Segmental Cardiac Radiation Dose Determines Magnitude of Regional Cardiac Dysfunction. J Am Heart Assoc 2021; 10:e019476. [PMID: 33749308 PMCID: PMC8174310 DOI: 10.1161/jaha.120.019476] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Subclinical left ventricular dysfunction detected by 2‐dimensional global longitudinal strain post breast radiotherapy has been described in patients with breast cancer. We hypothesized that left ventricular dysfunction postradiotherapy may be site specific, based on differential segmental radiotherapy dose received. Methods and Results Transthoracic echocardiograms were performed at baseline, 6 weeks, and 12 months postradiotherapy on 61 chemotherapy‐naïve women with left‐sided breast cancer undergoing tangential breast radiotherapy. Radiation received within basal, mid, and apical regions for the 6 left ventricular walls was quantified from the radiotherapy treatment planning system. Anterior, anteroseptal, and anterolateral walls received the highest radiation doses, while inferolateral and inferior walls received the lowest. There was a progressive increase in the radiation dose received from basal to apical regions. At 6 weeks, the most significant percentage deterioration in strain was seen in the apical region, with greatest reductions in the anterior wall followed by the anteroseptal and anterolateral walls, with a similar pattern persisting at 12 months. There was a within‐patient dose–response association between the segment‐specific percentage deterioration in strain at 6 weeks and 12 months and the radiation dose received. Conclusions Radiotherapy for left‐sided breast cancer causes differential segmental dysfunction, with myocardial segments that receive the highest radiation dose demonstrating greatest strain impairment. Percentage deterioration in strain observed 6 weeks postradiotherapy persisted at 12 months and demonstrated a dose–response relationship with radiotherapy dose received. Radiotherapy‐induced subclinical cardiac dysfunction is of importance because it could be additive to chemotherapy‐related cardiotoxicity in patients with breast cancer. Long‐term outcomes in patients with asymptomatic strain reduction require further investigation.
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Affiliation(s)
- Siddharth J Trivedi
- Department of Cardiology Westmead Hospital Sydney NSW Australia.,Westmead Clinical School University of Sydney NSW Australia
| | - Simon Tang
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Central Coast Cancer Therapy Centre Gosford NSW Australia
| | - Karen Byth
- Research and Education Network Western Sydney Local Health DistrictWestmead Hospital Sydney NSW Australia.,NHMRC Clinical Trials CentreUniversity of Sydney NSW Australia
| | - Luke Stefani
- Department of Cardiology Westmead Hospital Sydney NSW Australia
| | - Queenie Lo
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Department of Cardiology St George Hospital Sydney NSW Australia
| | - James Otton
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Department of Cardiology Liverpool Hospital Sydney NSW Australia
| | - Michael Jameson
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - David Tran
- Department of Cardiology Liverpool Hospital Sydney NSW Australia
| | - Vikneswary Batumalai
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Lois Holloway
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Geoff P Delaney
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Eng-Siew Koh
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Liza Thomas
- Department of Cardiology Westmead Hospital Sydney NSW Australia.,Westmead Clinical School University of Sydney NSW Australia.,South Western Sydney Clinical School University of New South Wales Sydney NSW Australia
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Gebski V, Marschner I, Asher R, Byth K. Using recurrent time-to-event models with multinomial outcomes to generate toxicity profiles. Pharm Stat 2021; 20:840-849. [PMID: 33733578 DOI: 10.1002/pst.2113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/21/2020] [Revised: 01/20/2021] [Accepted: 03/02/2021] [Indexed: 12/20/2022]
Abstract
Most clinical studies, which investigate the impact of therapy simultaneously, record the frequency of adverse events in order to monitor safety of the intervention. Study reports typically summarise adverse event data by tabulating the frequencies of the worst grade experienced but provide no details of the temporal profiles of specific types of adverse events. Such 'toxicity profiles' are potentially important tools in disease management and in the assessment of newer therapies including targeted treatments and immunotherapy where different types of toxicity may be more common at various times during long-term drug exposure. Toxicity profiles of commonly experienced adverse events occurring due to exposure to long-term treatment could assist in evaluating the costs of the health care benefits of therapy. We show how to generate toxicity profiles using an adaptation of the ordinal time-to-event model comprising of a two-step process, involving estimation of the multinomial response probabilities using multinomial logistic regression and combining these with recurrent time to event hazard estimates to produce cumulative event probabilities for each of the multinomial adverse event response categories. Such a model permits the simultaneous assessment of the risk of events over time and provides cumulative risk probabilities for each type of adverse event response. The method can be applied more generally by using different models to estimate outcome/response probabilities. The method is illustrated by developing toxicity profiles for three distinct types of adverse events associated with two treatment regimens for patients with advanced breast cancer.
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Affiliation(s)
- Val Gebski
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Ian Marschner
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Rebecca Asher
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Karen Byth
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
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Evans L, Liu Y, Donovan B, Kwan T, Byth K, Harnett P. Improving Cancer MDT performance in Western Sydney - three years' experience. BMC Health Serv Res 2021; 21:203. [PMID: 33676492 PMCID: PMC7937192 DOI: 10.1186/s12913-021-06203-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Received: 10/15/2020] [Accepted: 02/22/2021] [Indexed: 11/22/2022] Open
Abstract
Background While multidisciplinary teams (MDTs) are now considered an essential part of cancer care decision-making, how they perform varies widely. The authors hypothesised that a comprehensive, multipronged improvement program, and associated annual member survey, could strengthen MDT performance across a whole cancer service. Methods The study comprised the introduction of a structured program, the Tumour Program Strengthening Initiative (TPSI) linked with an annual survey of member’s perceptions of their performance. Three iterations of the survey have been completed (2017, 2018 and 2019). Generalised estimating equations (GEEs) were used to test for a difference in the proportion of positive survey responses between 2017 and 2019 adjusted for team clustering. Results Twelve teams participated in TPSI. One hundred twenty-nine, 118 and 146 members completed the survey in 2017, 2018 and 2019, respectively. Of the 17 questions that were asked in all three years, nine showed significant improvement and, of these, five were highly significant. Documenting consensus, developing Terms of Reference (TORs), establishing referral criteria and referring to clinical practice guidelines showed most improvement. Questions related to patient considerations, professional development and quality improvement (QI) activities showed no significant change. Conclusions TPSI resulted in sustained and significant improvement. The MDT survey not only allowed MDT members to identify their strengths and weaknesses but also provided insights for management to flag priority areas for further support. Overall program improvement reflected the strengthening of the weakest teams as well as further improvement in highly performing MDTs. Importantly, the initiative has the potential to achieve behaviour change amongst clinicians. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06203-y.
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Affiliation(s)
- Lynleigh Evans
- Sydney West - Translational Cancer Research Centre, Western Sydney Local Health District, PO Box 533 Wentworthville, Sydney, NSW, 2145, Australia.
| | - Yiren Liu
- Tumour Program Strengthening Initiative innovation manager (2019), Western Sydney Local Health District, Sydney, Australia
| | - Brendan Donovan
- Tumour Program Strengthening Initiative innovation manager (2018), Western Sydney Local Health District, Sydney, Australia
| | - Terence Kwan
- Faculty of Engineering and IT, University of Sydney, Sydney, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Sydney, Australia
| | - Paul Harnett
- Sydney West - Translational Cancer Research Centre, Western Sydney Local Health District, PO Box 533 Wentworthville, Sydney, NSW, 2145, Australia
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Gupta S, Sidhu M, Banh X, Bradbear J, Byth K, Hourigan LF, Raftopoulos S, Bourke MJ. A prospective multicentre study of per-oral endoscopic myotomy (POEM) for achalasia in Australia. Med J Aust 2021; 214:173-178. [PMID: 33611796 DOI: 10.5694/mja2.50941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 12/22/2019] [Accepted: 10/09/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To describe the clinical and procedural outcomes of per-oral endoscopic myotomy (POEM) for achalasia in Australia. DESIGN, SETTING Prospective observational study in three Australian tertiary referral centres, 5 May 2014 - 27 October 2019 (66 months). PARTICIPANTS Patients who had undergone POEM for achalasia. MAJOR OUTCOME MEASURES Eckardt scores calculated prior to POEM and six months, one year, and two years after POEM. The primary outcome was clinical success, defined as an Eckardt score of 3 or less without a second intervention. RESULTS 142 patients underwent POEM for achalasia; their mean age was 52 years (SD, 18 years), 83 were men (58%), and the median length of hospital stay two days (IQR, 1-3 days). Their mean Eckardt score before POEM was 8.0 (SD, 2.4) and 1.1 (SD, 1.6) six months after POEM; it did not change significantly between six months and two years after POEM (mean monthly increase, 0.014 points; 95% CI, -0.001 to 0.029). A total of 127 patients (89%) improved clinically after POEM. Intra-procedural capnoperitoneum was the only risk factor associated with treatment failure (adjusted hazard ratio, 2.85; 95% CI, 1.08-7.51). Previous treatments - botulinum toxin injection (25 patients, 18%), endoscopic balloon dilatation (69, 49%), and Heller myotomy (14, 10%) - did not affect POEM outcomes. Five patients (4%) experienced major adverse events, including pneumonia, oesophageal leak, empyema and melaena, that were managed during admission and without sequelae. CONCLUSIONS POEM is an effective treatment for achalasia. Significant reductions in Eckardt scores achieved by six months are sustained at two years. POEM can be both a first line definitive therapy and a salvage therapy for patients not helped by other treatments.
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Affiliation(s)
- Sunil Gupta
- Westmead Hospital, Sydney, NSW.,Westmead Clinical School, University of Sydney, Sydney, NSW
| | - Mayenaaz Sidhu
- Westmead Hospital, Sydney, NSW.,Westmead Clinical School, University of Sydney, Sydney, NSW
| | - Xuan Banh
- Princess Alexandra Hospital Health Service District, Brisbane, QLD
| | - Joseph Bradbear
- Princess Alexandra Hospital Health Service District, Brisbane, QLD
| | - Karen Byth
- Western Sydney Local Health District Research and Education Network, Sydney, NSW.,NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW
| | - Luke F Hourigan
- Princess Alexandra Hospital Health Service District, Brisbane, QLD.,Gallipoli Medical Research Institute, University of Queensland, Brisbane, QLD
| | | | - Michael J Bourke
- Westmead Hospital, Sydney, NSW.,Westmead Clinical School, University of Sydney, Sydney, NSW
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Ferkh A, Stefani L, Trivedi SJ, Brown P, Byth K, Pathan F, Thomas L. Inter-vendor comparison of left atrial strain using layer specific strain analysis. Int J Cardiovasc Imaging 2021; 37:1279-1288. [PMID: 33389361 DOI: 10.1007/s10554-020-02114-x] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 11/20/2020] [Indexed: 12/09/2022]
Abstract
Left atrial strain (LAS) on transthoracic echocardiogram (TTE) is increasingly recognised to have clinical utility in cardiovascular disease. Differences in LAS measurements between vendors remains a barrier for clinical use. We sought to compare LAS between two commonly used software platforms; the layer-specific endocardial and mid-myocardial measurements of LAS on General Electric (GE) Echopac were compared to TomTec strain. LAS was measured in 88 individuals with no previous cardiac history and 40 paroxysmal AF (PAF) patients, in sinus rhythm at TTE. Conventionally, LAS measured using GE Echopac is mid-myocardial strain (GE-mid); additionally, endocardial (GE-endo) LAS was evaluated. Both LAS measurements by GE were compared to TomTec-Arena (v2.30.02) measurements. Reservoir (ƐR), contractile (ƐCT) and conduit (ƐCD) phasic strain were evaluated. Both GE-mid and GE-endo LAS correlated well with TomTec LAS. On Bland-Altman analysis, GE-mid LAS measurements were systematically lower than TomTec LAS (ƐR: mean difference (MD) - 6.08%, limits of agreement (LOA) - 12%, 0%, ƐCT: MD - 0.8%, LOA - 7%, 5%, ƐCD: MD - 5.2% LOA - 12%, 1%). GE-endo LAS demonstrated no systematic difference from TomTec LAS, but had wider limits of agreement (ƐR: MD 0.41%, LOA - 7%, 8%, ƐCT: MD 0.50%, LOA - 6%, 7%, ƐCD: MD - 0.08%, LOA - 7%, 7%). ƐR had the best reproducibility. Mid-myocardial LAS, routinely evaluated by GE Echopac software, systematically underestimates LAS compared to TomTec. Using GE endocardial LAS eliminated this bias, but introduced greater variation between measurements. Serial measurements of LAS should therefore be performed on the same vendor system.
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Affiliation(s)
- Aaisha Ferkh
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.,Cardiology Department, Westmead Hospital, Westmead, Australia.,Western Sydney Local Health District - Research and Education Network, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Luke Stefani
- Cardiology Department, Westmead Hospital, Westmead, Australia.,Western Sydney Local Health District - Research and Education Network, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Siddharth J Trivedi
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.,Cardiology Department, Westmead Hospital, Westmead, Australia.,Western Sydney Local Health District - Research and Education Network, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Paula Brown
- Cardiology Department, Westmead Hospital, Westmead, Australia.,Western Sydney Local Health District - Research and Education Network, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Karen Byth
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.,Western Sydney Local Health District - Research and Education Network, Westmead Hospital, Westmead, NSW, 2145, Australia.,NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, 2006, Australia
| | - Faraz Pathan
- Western Sydney Local Health District - Research and Education Network, Westmead Hospital, Westmead, NSW, 2145, Australia.,Charles Perkins Centre, University of Sydney ,University of Sydney, Nepean Clinical School, Sydney, NSW, Australia.,Cardiology Department, Nepean Hospital, Sydney, Australia
| | - Liza Thomas
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia. .,Cardiology Department, Westmead Hospital, Westmead, Australia. .,Western Sydney Local Health District - Research and Education Network, Westmead Hospital, Westmead, NSW, 2145, Australia. .,South Western Clinical School, University of New South Wales, Sydney, Sydney, Australia. .,Cardiology Department, Westmead Hospital, Corner Hawkesbury and Darcy Road, Westmead, NSW, 2145, Australia.
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Trivedi S, Bennett R, Byth K, Campbell T, Turnbull S, Stefani L, Kumar S, Thomas L. Speckle Tracking Echocardiography Predicts Arrhythmia Recurrence in Patients With Structural Heart Disease Following Ventricular Tachycardia Ablation. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.012] [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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43
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Gan GCH, Bhat A, Chen HHL, Gu KH, Fernandez F, Kadappu KK, Byth K, Eshoo S, Thomas L. Left Atrial Reservoir Strain by Speckle Tracking Echocardiography: Association With Exercise Capacity in Chronic Kidney Disease. J Am Heart Assoc 2020; 10:e017840. [PMID: 33372523 PMCID: PMC7955492 DOI: 10.1161/jaha.120.017840] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Left atrial (LA) function plays a pivotal role in modulating left ventricular performance. The aim of our study was to evaluate the relationship between resting LA function by strain analysis and exercise capacity in patients with chronic kidney disease (CKD) and evaluate its utility compared with exercise E/e'. Methods and Results Consecutive patients with stage 3 and 4 CKD without prior cardiac history were prospectively recruited from outpatient nephrology clinics and underwent clinical evaluation and resting and exercise stress echocardiography. Resting echocardiographic parameters including E/e' and phasic LA strain (LA reservoir [LASr], conduit, and contractile strain) were measured and compared with exercise E/e'. A total of 218 (63.9±11.7 years, 64% men) patients with CKD were recruited. Independent clinical parameters associated with exercise capacity were age, estimated glomerular filtration rate, body mass index, and sex (P<0.01 for all), while independent resting echocardiographic parameters included E/e', LASr, and LA contractile strain (P<0.01 for all). Among resting echocardiographic parameters, LASr demonstrated the strongest positive correlation to metabolic equivalents achieved (r=0.70; P<0.01). Receiver operating characteristic curves demonstrated that LASr (area under the curve, 0.83) had similar diagnostic performance as exercise E/e' (area under the curve, 0.79; P=0.20 on DeLong test). A model combining LASr and clinical metrics showed robust association with metabolic equivalents achieved in patients with CKD. Conclusions LASr, a marker of decreased LA compliance is an independent correlate of exercise capacity in patients with stage 3 and 4 CKD, with similar diagnostic value to exercise E/e'. Thus, LASr may serve as a resting biomarker of functional capacity in this population.
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Affiliation(s)
- Gary C H Gan
- Department of Cardiology Blacktown Hospital Sydney NSW Australia.,Department of Cardiology Westmead Hospital Sydney NSW Australia.,University of New South Wales Sydney NSW Australia.,Western Sydney University Sydney NSW Australia
| | - Aditya Bhat
- Department of Cardiology Blacktown Hospital Sydney NSW Australia.,University of New South Wales Sydney NSW Australia.,Western Sydney University Sydney NSW Australia
| | - Henry H L Chen
- Department of Cardiology Blacktown Hospital Sydney NSW Australia
| | - Kennith H Gu
- Department of Cardiology Blacktown Hospital Sydney NSW Australia.,Western Sydney University Sydney NSW Australia
| | | | - Krishna K Kadappu
- University of New South Wales Sydney NSW Australia.,Western Sydney University Sydney NSW Australia.,Department of Cardiology Liverpool Hospital Sydney NSW Australia.,Department of Cardiology Campbelltown Hospital Sydney NSW Australia
| | - Karen Byth
- Research and Education Network Western Sydney Local Health District Sydney NSW Australia
| | - Suzanne Eshoo
- Department of Cardiology Blacktown Hospital Sydney NSW Australia.,Western Sydney University Sydney NSW Australia
| | - Liza Thomas
- Department of Cardiology Westmead Hospital Sydney NSW Australia.,University of New South Wales Sydney NSW Australia.,University of Sydney Sydney NSW Australia
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Gan GCH, Kadappu KK, Bhat A, Fernandez F, Gu KH, Cai L, Byth K, Eshoo S, Thomas L. Left Atrial Strain Is the Best Predictor of Adverse Cardiovascular Outcomes in Patients with Chronic Kidney Disease. J Am Soc Echocardiogr 2020; 34:166-175. [PMID: 33223356 DOI: 10.1016/j.echo.2020.09.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) are at increased risk of adverse cardiovascular events, which is underestimated by traditional risk stratification algorithms. We sought to determine clinical and echocardiographic predictors of adverse outcomes in CKD patients. METHODS Two hundred forty-three prospectively recruited stage 3/4 CKD patients (male, 63%; mean age, 59.2 ± 14.4 years) without previous cardiac disease made up the study cohort. All participants underwent a transthoracic echocardiogram, with left ventricular (LV) and left atrial (LA) strain analysis. Participants were followed for 3.9 ± 2.7 years for the primary end point of cardiovascular death and major adverse cardiovascular event (MACE). The secondary end point was the composite of all-cause death and MACE. RESULTS Fifty-four patients met the primary end point, and 65 the secondary end point. On log-rank tests, older age, diabetes mellitus, anemia, greater LV mass, reduced LV global longitudinal strain, larger indexed LA volume, higher E/e' ratio, and reduced LA reservoir strain (LASr; P < .01 for all) were independent predictors of cardiovascular death and MACE. On multivariable regression analysis of univariate predictors, LASr (P < .01) was the only independent predictor for the primary end point as well as for the secondary end point. Receiver operating characteristic curve analysis showed LASr was a stronger predictor of adverse events (area under the curve [AUC] = 0.84) compared to the Framingham (AUC = 0.58) and Atherosclerotic Cardiovascular Disease (AUC = 0.59) risk scores. CONCLUSIONS LASr is an independent predictor of cardiovascular death and MACE in CKD patients, superior to clinical risk scores, LV parameters, and LA volume.
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Affiliation(s)
- Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
| | - Krishna K Kadappu
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia; Department of Cardiology, Campbelltown Hospital, Sydney, New South Wales, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
| | - Fernando Fernandez
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Kennith H Gu
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Lawrence Cai
- University of New South Wales, Sydney, New South Wales, Australia
| | - Karen Byth
- Biostatistics Unit, Research and Education Network, Westmead Hospital, and the University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Eshoo
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
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45
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Gan GCH, Bhat A, Chen HHL, Fernandez F, Byth K, Eshoo S, Thomas L. Determinants of LA reservoir strain: Independent effects of LA volume and LV global longitudinal strain. Echocardiography 2020; 37:2018-2028. [PMID: 33211337 DOI: 10.1111/echo.14922] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 09/05/2020] [Revised: 10/22/2020] [Accepted: 10/25/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Left atrial (LA) deformation during the reservoir phase (LASr) has demonstrated strong prognostic value in different clinical settings. Although determinants of left atrial reservoir strain including left atrial relaxation, left atrial compliance, and left ventricular longitudinal systolic function are fairly well defined, there is incomplete information regarding the effect of left atrial volume on this relationship which is the focus of our study. METHOD Consecutive patients without prior cardiac disease referred for transthoracic echocardiography were prospectively recruited. All participants underwent clinical assessment, transthoracic echocardiography (TTE), and screening exercise stress test. Only patients with normal left ventricular ejection fraction (LVEF) without left ventricular hypertrophy (LVH) or myocardial ischemia on stress testing were included. RESULTS A total of 260 patients (57% male, mean age 59 ± 14 years) were included. 70% had hypertension, 33% had diabetes mellitus, and 31% had both HTN and DM. On multivariate analysis, age, e', LAVI, and LV GLS (P < .01 for all) showed an independent association with LASr. Of interest, at lower tertiles of LAVI, a linear decrease in LASr was observed parallel to worsening LV GLS, whilst at higher tertiles of LAVI, the reduction in LASr was non-linear implying that LA enlargement, consequent to LA remodeling, had an incremental effect on LASr. CONCLUSION Age, e', LV GLS, and LAVI were independently associated with LASr. LA remodeling reflected by larger LAVI had an incremental negative association with LASr independent of LV GLS.
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Affiliation(s)
- Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, NSW, Australia.,Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Western Sydney University, Sydney, NSW, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Western Sydney University, Sydney, NSW, Australia
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, NSW, Australia
| | - Fernando Fernandez
- Department of Cardiology, Blacktown Hospital, Sydney, NSW, Australia.,Western Sydney University, Sydney, NSW, Australia
| | - Karen Byth
- Biostatistics Unit, Research and Education Network, Westmead Hospital and The University of Sydney, Sydney, NSW, Australia
| | - Suzanne Eshoo
- Department of Cardiology, Blacktown Hospital, Sydney, NSW, Australia.,Western Sydney University, Sydney, NSW, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
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Gebski V, Byth K, Asher R, Marschner I. Recurrent time-to-event models with ordinal outcomes. Pharm Stat 2020; 20:77-92. [PMID: 33006268 DOI: 10.1002/pst.2057] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/20/2020] [Accepted: 07/21/2020] [Indexed: 11/07/2022]
Abstract
A model to accommodate time-to-event ordinal outcomes was proposed by Berridge and Whitehead. Very few studies have adopted this approach, despite its appeal in incorporating several ordered categories of event outcome. More recently, there has been increased interest in utilizing recurrent events to analyze practical endpoints in the study of disease history and to help quantify the changing pattern of disease over time. For example, in studies of heart failure, the analysis of a single fatal event no longer provides sufficient clinical information to manage the disease. Similarly, the grade/frequency/severity of adverse events may be more important than simply prolonged survival in studies of toxic therapies in oncology. We propose an extension of the ordinal time-to-event model to allow for multiple/recurrent events in the case of marginal models (where all subjects are at risk for each recurrence, irrespective of whether they have experienced previous recurrences) and conditional models (subjects are at risk of a recurrence only if they have experienced a previous recurrence). These models rely on marginal and conditional estimates of the instantaneous baseline hazard and provide estimates of the probabilities of an event of each severity for each recurrence over time. We outline how confidence intervals for these probabilities can be constructed and illustrate how to fit these models and provide examples of the methods, together with an interpretation of the results.
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Affiliation(s)
- Val Gebski
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Karen Byth
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Rebecca Asher
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Ian Marschner
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
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Ferkh A, O'Keefe E, Zada M, Brown P, Duggins A, Thiagalingam A, Altman M, Byth K, Kizana E, Denniss AR, Thomas L. Demographic and clinical profile of cardioembolic stroke patients in Western Sydney. Intern Med J 2020; 50:726-732. [DOI: 10.1111/imj.14416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/19/2019] [Accepted: 06/23/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Aaisha Ferkh
- University of Sydney Sydney New South Wales Australia
- Department of CardiologyWestmead Hospital Sydney New South Wales Australia
| | - Emily O'Keefe
- Department of CardiologyWestmead Hospital Sydney New South Wales Australia
| | - Matthew Zada
- Department of CardiologyWestmead Hospital Sydney New South Wales Australia
| | - Paula Brown
- Department of CardiologyWestmead Hospital Sydney New South Wales Australia
| | - Andrew Duggins
- Department of NeurologyWestmead Hospital Sydney New South Wales Australia
| | - Aravinda Thiagalingam
- University of Sydney Sydney New South Wales Australia
- Department of CardiologyWestmead Hospital Sydney New South Wales Australia
| | - Mikhail Altman
- Department of CardiologyWestmead Hospital Sydney New South Wales Australia
| | - Karen Byth
- University of Sydney Sydney New South Wales Australia
| | - Eddy Kizana
- University of Sydney Sydney New South Wales Australia
- Department of CardiologyWestmead Hospital Sydney New South Wales Australia
- Westmead Institute of Medical Research Sydney New South Wales Australia
| | - Alan R. Denniss
- University of Sydney Sydney New South Wales Australia
- Department of CardiologyWestmead Hospital Sydney New South Wales Australia
| | - Liza Thomas
- University of Sydney Sydney New South Wales Australia
- Department of CardiologyWestmead Hospital Sydney New South Wales Australia
- South Western Clinical SchoolUniversity of New South Wales Sydney New South Wales Australia
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Abstract
e19200 Background: While multidisciplinary teams (MDTs) are considered the “gold standard” of care for cancer patients, their performance varies widely. This study aimed to develop a user friendly, reliable and valid self-assessment tool for MDTs to evaluate their performance and monitor improvement over time. Methods: Using maturity modelling methodology, key themes from the literature were developed into a 2-dimensional matrix comprising 17 indicators (within 6 components) across 5 levels of performance. A modified Delphi methodology (where 38 MDT members each assigned the contents to components and performance levels using card sorting software) was used to establish face and content validity. A 10 minute on-line version of the matrix was piloted across 11 MDTs. Each participant estimated where they thought the MDT performed for each indicator. Correlation and factor analyses examining convergent and discriminant validity were conducted using SPSS. Cronbach alpha was used to measure internal consistency and evaluate reliability. Ease of use and usefulness were also examined. Results: A total of 109 members completed the matrix, with representation from medical, nursing and allied health professionals. The mean results for each indicator are shown below (maximum 5). Overall results for the different teams varied from 1.2 to 4.2, with standard deviations ranging from 0.4 to 0.8. Conclusions: This matrix has the potential to be a simple, valid and reliable tool for MDTs to measure their performance and monitor improvement over time. The tool will now be refined and then disseminated to a wider audience for further validation and feedback. [Table: see text]
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Affiliation(s)
- Lynleigh Evans
- Western Sydney Local Health District, Milsons Point, NSW, Australia
| | - Yiren Liu
- Western Sydney Local Health District, Westmead, Australia
| | | | | | - Karen Byth
- Western Sydney Local Health District, Westmead, Australia
| | | | - Paul R. Harnett
- Crown Princess Mary Cancer Centre Westmead, Sydney, Australia
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Evans L, Liu Y, Kwan T, Donovan B, Byth K, Harnett PR. Implementing a tumor program strengthening initiative in western Sydney. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e19223] [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: 11/20/2022] Open
Abstract
e19223 Background: While multidisciplinary teams (MDTs) are well-established in many healthcare institutions, both how they function and their role in decision making vary widely. This study assessed the effectiveness of a multipronged approach to strengthening multidisciplinary team performance for a cancer service over three years. Methods: The study comprised the introduction of a structured quality improvement program, the Tumour Program Strengthening Initiative (TPSI), to improve MDT performance, and an annual survey to evaluate MDT members’ perceptions of their teams’ performance. Three iterations of the survey have been completed. Results: 12 teams participated in TPSI with 129, 118, and 146 members completing the MDT member survey in 2017, 2018, and 2019 respectively. Of the 18 questions that were asked throughout the study, nine showed significant improvement, and of these, seven were highly significant. Questions related to patient wellbeing and to audits and quality improvement showed no significant change. Conclusions: The Tumour Program Strengthening Initiative resulted in sustained and significant improvement in MDT performance over three years. The MDT survey proved to be useful not only for cancer care teams to identify their strengths and weaknesses and monitoring performance but also for management to flag priority areas for improvement and further support. The significance of this initiative is that overall program improvement reflects the strengthening of the weakest teams as well as further improvement in highly performing MDTs. [Table: see text]
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Affiliation(s)
- Lynleigh Evans
- Western Sydney Local Health District, Milsons Point, NSW, Australia
| | - Yiren Liu
- Western Sydney Local Health District, Westmead, Australia
| | | | | | - Karen Byth
- Western Sydney Local Health District, Westmead, Australia
| | - Paul R. Harnett
- Crown Princess Mary Cancer Centre Westmead, Sydney, Australia
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Trivedi SJ, Terluk AD, Kritharides L, Chow V, Chia EM, Byth K, Mussap CJ, Ng ACC, Thomas L. Right ventricular speckle tracking strain echocardiography in patients with acute pulmonary embolism. Int J Cardiovasc Imaging 2020; 36:865-872. [DOI: 10.1007/s10554-020-01779-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/24/2020] [Indexed: 12/31/2022]
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