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Choucair K, Nebhan C, Cortellini A, Hentzen S, Wang Y, Liu C, Giusti R, Filetti M, Ascierto PA, Vanella V, Galetta D, Catino A, Al-Bzour N, Saeed A, Cavalcante L, Pizzutilo P, Genova C, Bersanelli M, Buti S, Johnson DB, Fulgenzi CAM, Pinato DJ, Radford M, Kim C, Naqash AR, Saeed A. Characterization of Age-Associated, Neutrophil-to-Lymphocyte Ratio (NLR) and Systemic Immune-Inflammatory Index (SII) as Biomarkers of Inflammation in Geriatric Patients with Cancer Treated with Immune Checkpoint Inhibitors: Impact on Efficacy and Survival. Cancers (Basel) 2023; 15:5052. [PMID: 37894419 PMCID: PMC10605297 DOI: 10.3390/cancers15205052] [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: 09/18/2023] [Revised: 10/10/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Geriatric patients (≥80 years) are underrepresented in immune checkpoint inhibitor (ICIs) clinical trials. However, their unique biology may affect their response to ICIs. There are currently no established biomarkers of the response to ICIs in adult patients with cancer that can help with patient selection. METHODS We built a multicenter, international retrospective study of 885 patients (<80 years: n = 417, 47.12%; ≥80 years: n = 468, 52.88%) with different tumor types treated with ICIs between 2011 and 2021 from 11 academic centers in the U.S. and Europe. The main outcome measures were objective response rates (ORR), progression-free survival (PFS) and overall survival (OS) stratified by age and circulating inflammatory levels (neutrophil-to-lymphocyte ratio (NLR) and systemic immune-inflammatory index (SII)). RESULTS Patients ≥80 years with low NLR (NLR-L) and SII (SII-L) had significantly higher ORR (vs. high NLR [NLR-H], p < 0.01 and SII-H, p < 0.05, respectively). At median follow-ups (13.03 months), and compared to SII-H, patients with SII-L had significantly longer median PFS and OS in patients <80 (p < 0.001), and ≥80 years (p < 0.001). SII-L was independently associated with longer PFS and OS (HR: 0.61 and 0.62, respectively, p < 0.01). CONCLUSION Lower inflammation pre-ICI initiation may predict an improved response and survival in geriatric patients with cancer.
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Affiliation(s)
- Khalil Choucair
- Barbara Ann Karmanos Cancer Institute, Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48201, USA;
| | - Caroline Nebhan
- Vanderbilt-Ingram Cancer Center, Nashville, TN 37232, USA; (C.N.); (D.B.J.)
| | - Alessio Cortellini
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College London, London SW7 2BX, UK; (A.C.); (C.A.M.F.); (D.J.P.)
- Operative Research Unit of Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
| | - Stijn Hentzen
- Department of Medicine, Kansas University Medical Center, Kansas City, KS 66211, USA; (S.H.); (M.R.)
| | - Yinghong Wang
- The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Cynthia Liu
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Raffaele Giusti
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Sant’Andrea, 00189 Rome, Italy;
| | - Marco Filetti
- Phase 1 Unit, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 71013 Rome, Italy;
| | - Paolo Antonio Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, 80131 Napoli, Italy; (P.A.A.); (V.V.)
| | - Vito Vanella
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, 80131 Napoli, Italy; (P.A.A.); (V.V.)
| | - Domenico Galetta
- Medical Thoracic Oncology Unit, IRCCS Istituto Tumori Giovanni Paolo II, 70124 Bari, Italy; (D.G.); (A.C.); (P.P.)
| | - Annamaria Catino
- Medical Thoracic Oncology Unit, IRCCS Istituto Tumori Giovanni Paolo II, 70124 Bari, Italy; (D.G.); (A.C.); (P.P.)
| | - Nour Al-Bzour
- UPMC Hillman Cancer Center, Department of Medicine, Division of Hematology and Oncology, University of Pittsburgh, Pittsburgh, PA 15232, USA;
| | - Azhar Saeed
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, VT 05401, USA;
| | | | - Pamela Pizzutilo
- Medical Thoracic Oncology Unit, IRCCS Istituto Tumori Giovanni Paolo II, 70124 Bari, Italy; (D.G.); (A.C.); (P.P.)
| | - Carlo Genova
- UOC Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Dipartimento di Medicina Interna e Specialità Mediche, Università degli Studi di Genova, 16126 Genova, Italy
| | | | - Sebastiano Buti
- Medicine and Surgery Department, University of Parma, 43121 Parma, Italy;
| | - Douglas B. Johnson
- Vanderbilt-Ingram Cancer Center, Nashville, TN 37232, USA; (C.N.); (D.B.J.)
| | - Claudia Angela Maria Fulgenzi
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College London, London SW7 2BX, UK; (A.C.); (C.A.M.F.); (D.J.P.)
- Operative Research Unit of Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
| | - David J. Pinato
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College London, London SW7 2BX, UK; (A.C.); (C.A.M.F.); (D.J.P.)
| | - Maluki Radford
- Department of Medicine, Kansas University Medical Center, Kansas City, KS 66211, USA; (S.H.); (M.R.)
| | - Chul Kim
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA;
| | - Abdul Rafeh Naqash
- Medical Oncology/Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK 73019, USA;
| | - Anwaar Saeed
- UPMC Hillman Cancer Center, Department of Medicine, Division of Hematology and Oncology, University of Pittsburgh, Pittsburgh, PA 15232, USA;
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Radford M, Abushukair H, Hentzen S, Cavalcante L, Saeed A. Targeted and Immunotherapy Approaches in HER2-Positive Gastric and Gastroesophageal Junction Adenocarcinoma: A New Era. J Immunother Precis Oncol 2023; 6:150-157. [PMID: 37637236 PMCID: PMC10448730 DOI: 10.36401/jipo-22-36] [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] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/28/2023] [Accepted: 05/05/2023] [Indexed: 08/29/2023]
Abstract
HER2-targeted therapy with the HER2 monoclonal antibody trastuzumab has achieved impressive outcomes in the first-line settings of patients with advanced gastric and gastroesophageal junction (GEJ) adenocarcinoma overexpressing HER2. However, considering that a substantial proportion of those patients eventually relapses, as well as the relatively limited performance of those agents in second-line settings, a deeper understanding of resistance mechanisms is needed for enhanced guidance for patients' therapeutic selection in the second-line setting and beyond. In this review, we highlight trastuzumab's (HER2-targeting agent) performance in patients with gastric or GEJ cancer, with insight into mechanisms of resistance. We also discuss the new integration of PD-1 inhibitor pembrolizumab into the trastuzumab for gastric cancer frontline regimen, the latest addition of trastuzumab deruxtecan to the treatment armamentarium, and the potential of pipeline HER2-targeting approaches and combinations in patients with gastric or GEJ adenocarcinoma.
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Affiliation(s)
- Maluki Radford
- Department of Medicine, Division of Medical Oncology, Kansas University Medical Center, Kansas City, KS, USA
| | - Hassan Abushukair
- Department of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Stijn Hentzen
- Department of Medicine, Division of Medical Oncology, Kansas University Medical Center, Kansas City, KS, USA
| | - Ludimila Cavalcante
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Anwaar Saeed
- Department of Medicine, Division of Hematology and Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
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3
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Nebhan CA, Cortellini A, Ma W, Ganta T, Song H, Ye F, Irlmeier R, Debnath N, Saeed A, Radford M, Alahmadi A, Diamond A, Hoimes C, Ramaiya N, Presley CJ, Owen DH, Abou Alaiwi S, Nassar A, Ricciuti B, Lamberti G, Bersanelli M, Casartelli C, Buti S, Marchetti P, Giusti R, Filetti M, Vanella V, Mallardo D, Macherla S, Sussman TA, Botticelli A, Galetta D, Catino A, Pizzutilo P, Genova C, Dal Bello MG, Kalofonou F, Daniels E, Ascierto PA, Pinato DJ, Choueiri TK, Johnson DB, Marron TU, Wang Y, Naqash AR. Clinical Outcomes and Toxic Effects of Single-Agent Immune Checkpoint Inhibitors Among Patients Aged 80 Years or Older With Cancer: A Multicenter International Cohort Study. JAMA Oncol 2021; 7:1856-1861. [PMID: 34734989 DOI: 10.1001/jamaoncol.2021.4960] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Geriatric (aged ≥80 years) patients are historically underrepresented in cancer clinical trials. Little is known about the efficacy of immune checkpoint inhibitors (ICIs) in geriatric patients. These agents are associated with immune-related adverse events (irAEs), which may be particularly associated with morbidity in this population. Objective To provide insight into the clinical outcomes and safety of ICIs among geriatric patients (aged ≥80 years) with cancer. Design, Setting, and Participants A Multicenter, international retrospective study of 928 geriatric patients with different tumors treated with single-agent ICIs between 2010 to 2019 from 18 academic centers in the US and Europe. Analyses were conducted from January 2021 to April 2021. Main Outcomes and Measures Clinical outcomes and irAE patterns in geriatric patients treated with single-agent ICIs. Results Median (range) age of the 928 patients at ICI initiation was 83.0 (75.8-97.0) years. Most patients (806 [86.9%]) were treated with anti-programmed cell death 1 therapy. Among the full cohort, the 3 most common tumors were non-small cell lung cancer (NSCLC, 345 [37.2%]), melanoma (329 [35.5%]), and genitourinary (GU) tumors (153 [16.5%]). Objective response rates for patients with NSCLC, melanoma, and GU tumors were 32.2%, 39.3%, and 26.2%, respectively. Median PFS and OS, respectively, were 6.7 and 10.9 months (NSCLC), 11.1 and 30.0 months (melanoma), and 6.0 and 15.0 months (GU). Within histologically specific subgroups (NSCLC, melanoma, and GU), clinical outcomes were similar across age subgroups (aged <85 vs ≥85 years). Among all 928 patients, 383 (41.3%) experienced ≥1 irAE(s), including 113 (12.2%) that were reported to be grade (G) 3 to 4 based on Common Terminology Criteria for Adverse Events (version 5.0). The median time to irAE onset was 9.8 weeks; 219 (57%) occurred within the first 3 months after ICI initiation. Discontinuation of treatment with ICIs owing to irAEs occurred in 137 (16.1%) patients. There was no significant difference in the rate of irAEs among patients aged younger than 85, 85 to 89, and 90 years or older. Despite the similar rate of G3 or higher irAEs, ICIs were discontinued owing to irAEs more than twice as often among patients aged 90 years or older compared with patients younger than 90 years (30.9% vs 15.1%, P = .008). Conclusions and Relevance The findings of this international cohort study suggest that treatment with ICIs may be effective and generally well tolerated among older patients with cancer, though ICI discontinuation owing to irAEs was more frequent with increasing age.
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Affiliation(s)
| | - Alessio Cortellini
- Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.,Department of Surgery and Cancer, Imperial College London, London United Kingdom
| | - Weijie Ma
- The University of Texas MD Anderson Cancer Center, Houston.,Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Teja Ganta
- Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Haocan Song
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca Irlmeier
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neha Debnath
- Icahn School of Medicine at Mount Sinai, New York City, New York
| | | | | | - Asrar Alahmadi
- Case Western Reserve University, Division of Hematology & Oncology, Cleveland, Ohio.,Ohio State University, The James Comprehensive Cancer Center, Columbus
| | - Akiva Diamond
- Case Western Reserve University, Division of Hematology & Oncology, Cleveland, Ohio.,Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Christopher Hoimes
- Case Western Reserve University, Division of Hematology & Oncology, Cleveland, Ohio.,Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Nikhil Ramaiya
- Case Western Reserve University, Division of Hematology & Oncology, Cleveland, Ohio
| | | | - Dwight H Owen
- The Ohio State University Comprehensive Cancer Center, Columbus
| | | | - Amin Nassar
- Dana-Farber Cancer Center, Boston, Massachusetts
| | - Biagio Ricciuti
- Department of Medical Oncology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Giuseppe Lamberti
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Melissa Bersanelli
- Medical Oncology Unit, University Hospital of Parma and Medicine and Surgery Department, University of Parma, Parma, Italy
| | - Chiara Casartelli
- Medical Oncology Unit, University Hospital of Parma and Medicine and Surgery Department, University of Parma, Parma, Italy
| | - Sebastiano Buti
- Medical Oncology Unit, University Hospital of Parma and Medicine and Surgery Department, University of Parma, Parma, Italy
| | - Paolo Marchetti
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Sant'Andrea, Rome, Italy
| | - Raffaele Giusti
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Sant'Andrea, Rome, Italy
| | - Marco Filetti
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Sant'Andrea, Rome, Italy
| | - Vito Vanella
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | | | - Shravanti Macherla
- East Carolina University Brody School of Medicine, Division of Hematology & Oncology, Greenville, North Carolina
| | - Tamara A Sussman
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Andrea Botticelli
- Policlinico Umberto I, Clinical and Molecular Department, Sapienza University of Rome, Rome, Italy
| | - Domenico Galetta
- IRCCS Istituto Tumori Giovanni Paolo II, Medical Thoracic Oncology Unit, Bari, Italy
| | - Annamaria Catino
- IRCCS Istituto Tumori Giovanni Paolo II, Medical Thoracic Oncology Unit, Bari, Italy
| | - Pamela Pizzutilo
- IRCCS Istituto Tumori Giovanni Paolo II, Medical Thoracic Oncology Unit, Bari, Italy
| | - Carlo Genova
- UOC Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Dipartimento di Medicina Interna e Specialità Mediche, Università degli Studi di Genova, Genova, Italy
| | | | - Foteini Kalofonou
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Ella Daniels
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - David J Pinato
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom.,Department of Translational Medicine, University of Piemonte Orientale "A. Avogadro", Novara, Italy
| | | | | | - Thomas U Marron
- Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Yinghong Wang
- The University of Texas MD Anderson Cancer Center, Houston
| | - Abdul Rafeh Naqash
- East Carolina University Brody School of Medicine, Division of Hematology & Oncology, Greenville, North Carolina.,Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, Maryland.,Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Oklahoma City
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4
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Nebhan C, Cortellini A, Ma W, Ganta T, Song H, Ye F, Irlmeier R, Debnath N, Saeed A, Radford M, Alahmadi A, Diamond A, Hoimes C, Ramaiya N, Presley C, Owen D, Alaiwi SA, Nassar A, Ricciuti B, Lamberti G, Bersanelli M, Casartelli C, Buti S, Marchetti P, Giusti R, Filetti M, Vanella V, Mallardo D, Macherla S, Sussman T, Botticelli A, Galetta D, Catino A, Pizzutilo P, Genova C, Bello MGD, Kalofonou F, Daniels E, Ascierto P, Pinato D, Choueiri T, Johnson D, Marron T, Wang Y, Naqash AR. 239 Efficacy and toxicity of single agent immune checkpoint inhibitors among adults with cancer aged ≥80 years: a multicenter international cohort study. J Immunother Cancer 2021. [DOI: 10.1136/jitc-2021-sitc2021.239] [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] [Indexed: 11/03/2022] Open
Abstract
BackgroundImmune checkpoint inhibitors (ICIs) are approved by the U.S. Food&Drug Administration in over 17 tumor types. Older adult patients make up about a quarter of all cancer patients but are historically understudied in cancer clinical trials. ICIs are associated with immune-related adverse events (irAEs), which may be particularly morbid for older adult patients with underlying comorbidities and impaired functional status. In this study, we provide insight into the real-world safety and efficacy of ICIs among older adult patients (≥80 years) with cancer.MethodsThis is a multicenter, international retrospective study of tumor-agnostic older adult patients with cancer treated with single-agent ICIs between 2010–2019 from 18 academic centers in the U.S. and Europe. A cohort of 928 patients aged ≥80 years during treatment with ICI was assembled and analyzed to evaluate clinical outcomes and irAE patterns in older adult patients treated with single-agent ICIs.ResultsMedian age at ICI initiation was 83.0 years (range 75.8–97.0). Most patients (86.9%) were treated with anti-PD-1 therapy. Among the full cohort, the three most common tumors were non-small cell lung cancer (NSCLC, 37.2%,n=345), melanoma (35.5%,n=329), and genitourinary (GU) tumors (16.5%,n=153). Objective response rates for patients with NSCLC, melanoma, and GU tumors were 32.2%, 39.3%, and 26.2%, respectively. Median progression-free survival (PFS) was 6.7 months (95%CI, 5.2–8.6) for patients with NSCLC, 11.1 months (95%CI, 8.9–16.0) for patients with melanoma, and 6.0 months (95% CI, 5.0–10.7) for patients with GU malignancy. Median overall survival (OS) was 10.9 months (95%CI, 8.6–13.1) for patients with NSCLC, 30.0 months (95%CI, 23.6–46.4) for patients with melanoma, and 15.0 months (95%CI 9.1–25.4) for GU patients (Figure 1A-C). Within histology-specific cohorts (NSCLC, melanoma and GU), clinical outcomes were similar across age subgroups (<85,85–89,>90). Among all patients (N=928), 41.3% experienced ≥1 irAE(s), including 12.2% reported to be grade (G)3–4. No irAE-related deaths occurred. The median time to irAE onset was 9.8 weeks; 57% occurred within the first 3 months after ICI initiation. ICI was discontinued due to irAEs in 16.1% patients. There was no significant difference in the rate of irAEs among patients age <85, 85–89, and ≥90 years (p=0.15). Despite similar rates of G3+ irAEs, ICIs were discontinued due to irAE more than twice as often among patients ≥90 years compared to patients <90 years (30.9% vs. 15.1%, p=0.008) (table 1).ConclusionsICIs are effective and generally well-tolerated among older patients with cancer. However, ICI discontinuation due to irAE is more frequent with increasing age.
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Choucair K, Radford M, Bansal A, Park R, Saeed A. Advances in immune therapies for the treatment of microsatellite instability‑high/deficient mismatch repair metastatic colorectal cancer (Review). Int J Oncol 2021; 59:74. [PMID: 34396449 PMCID: PMC8360619 DOI: 10.3892/ijo.2021.5254] [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: 05/14/2021] [Accepted: 07/23/2021] [Indexed: 11/29/2022] Open
Abstract
Microsatellite instability-high/deficient mismatch repair colorectal cancer (MSI-H/dMMR CRC) is a molecular subtype characterized by high-frequency mutations within DNA mismatch repair genes. Defects in the DNA mismatch repair machinery lead to subsequent frame-shift mutations, resulting in the generation of frame-shift peptides that serve as neoantigens. This has translated into exquisite sensitivity to immune checkpoint inhibitors (ICIs) and a significant clinical benefit from immune therapies in this patient population. The present article provides a comprehensive review of the advances in the field of immune therapies for MSI-H/dMMR metastatic CRC, with a focus on the major randomized clinical trials that led to Food and Drug Administration approval of specific ICIs for this population, a detailed review of the molecular background responsible for tumor response, as well as the mechanisms of resistance to ICI therapy. Finally, ongoing investigations of other immunotherapeutic strategies to address and overcome the challenges that currently limit response and long-term response to ICIs were presented.
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Affiliation(s)
- Khalil Choucair
- Department of Medicine, Kansas University School of Medicine, Wichita, KS 67214, USA
| | - Maluki Radford
- Department of Medicine, Kansas University Medical Center, Kansas City, KS 66205, USA
| | - Ajay Bansal
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Kansas Medical Center and Kansas Cancer Institute, Kansas City, KS 66205, USA
| | - Robin Park
- Department of Medicine, MetroWest Medical Center/Tufts University School of Medicine, Framingham, Massachusetts, MA 01702, USA
| | - Anwaar Saeed
- Department of Medicine, Division of Medical Oncology, Kansas University Cancer Center, Kansas City, KS 66205, USA
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Punekar YS, Parks D, Joshi M, Kaur S, Evitt L, Chounta V, Radford M, Jha D, Ferrante S, Sharma S, Van Wyk J, de Ruiter A. Effectiveness and safety of dolutegravir two-drug regimens in virologically suppressed people living with HIV: a systematic literature review and meta-analysis of real-world evidence. HIV Med 2021; 22:423-433. [PMID: 33529489 PMCID: PMC8248313 DOI: 10.1111/hiv.13050] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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] [Accepted: 12/01/2020] [Indexed: 01/21/2023]
Abstract
Objectives Dolutegravir (DTG) is widely recommended within three‐drug regimens. However, similar efficacy and tolerability have also been achieved with DTG within two‐drug regimens in clinical trials. This study evaluated the real‐world effectiveness and discontinuations in people living with HIV‐1 (PLHIV) switching to DTG with lamivudine (3TC) or rilpivirine (RPV). Methods This was a one‐arm meta‐analysis utilizing data from a systematic literature review. Data from real‐world evidence studies of DTG + RPV and DTG + 3TC were extracted, pooled and analysed. The primary outcome was the proportion of patients with viral failure (VF; ≥ 50 copies/mL in two consecutive measurements and/or ≥ 1000 copies/mL in a single measurement) at week 48 (W48) and week 96 (W96). Other outcomes included virological suppression (VS; < 50 copies/mL) and discontinuations (W48 and W96). Estimates were calculated for VF, VS as per snapshot (VSS) and on treatment analysis (VSOT), and discontinuations. Results Pooled mean estimates of VF for DTG + 3TC and DTG + RPV were 0.8% [95% confidence interval (CI): 0.4–1.3] and 0.6% (95% CI: 0.0–1.6), respectively, at W48. VSS rate at W48 was 85.0% (95% CI: 82.3–87.5) for DTG + 3TC regimen and 92.4% (95% CI: 85.0–97.7) in the DTG + RPV regimen. The DTG + 3TC and DTG + RPV regimens led to discontinuations in 13.6% (95% CI: 11.1–16.2) and 7.2% (95% CI: 2.1–14.4) of patients, respectively, at W48. Similar results were observed at W96. Conclusions Treatment with DTG + 3TC or DTG + RPV in clinical practice provides a low rate of VF and a high rate of VS when initiated in virologically suppressed PLHIV with diverse backgrounds.
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Affiliation(s)
| | - D Parks
- GlaxoSmithKline, Collegeville, PA, USA
| | - M Joshi
- GlaxoSmithKline Knowledge Centre, Gurgaon, India
| | - S Kaur
- Parexel India, Chandigarh, India
| | - L Evitt
- ViiV Healthcare, Brentford, UK
| | | | | | - D Jha
- GlaxoSmithKline Knowledge Centre, Gurgaon, India
| | | | - S Sharma
- Parexel India, Chandigarh, India
| | | | - A de Ruiter
- ViiV Healthcare, Brentford, UK.,Guy's and St Thomas' NHS Foundation Trust, London, UK
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7
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Okoli C, Schwenk A, Radford M, Myland M, Taylor S, Darley A, Barnes J, Fox A, Grimson F, Reeves I, Munshi S, Croucher A, Boxall N, Benn P, Paice A, van Wyk J, Khoo S. Polypharmacy and potential drug-drug interactions for people with HIV in the UK from the Climate-HIV database. HIV Med 2020; 21:471-480. [PMID: 32671950 PMCID: PMC7497154 DOI: 10.1111/hiv.12879] [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] [Subscribe] [Scholar Register] [Accepted: 04/28/2020] [Indexed: 11/30/2022]
Abstract
Objectives People with HIV (PWHIV) are likely to need therapies for comorbidities as they age. We assessed risk of drug–drug interactions (DDIs) in PWHIV. Methods The Climate‐HIV electronic recording system was used to cross‐sectionally analyse records from PWHIV aged ≥ 18 years attending four UK HIV units with a current antiretroviral (ARV) prescription in February 2018. Antiretroviral and non‐ARV medications were categorized by clinical significance of DDIs (University of Liverpool DDI tool). Potential DDIs were predicted using treatment guidelines for commonly recorded comorbidities. Results Among 4630 PWHIV (44% female), 41% were ≥ 50 years old. The average number of non‐ARV comedications increased from < 1 for patients aged ≤ 24 years to > 5 for patients aged ≥ 75 years; 65% were taking one or more non‐ARV comedications. The median (interquartile range) number of non‐ARVs was 1 (0–2) and 2 (1–5) for those aged < 50 and ≥ 50 years, respectively. Common comorbidities/concurrent health conditions occurred more frequently in patients aged ≥ 50 years vs. < 50 (53% vs. 34%). Boosted protease inhibitors were associated with the highest proportion of contraindicated comedications; dolutegravir and raltegravir had the fewest. For non‐ARVs, sildenafil and quetiapine were most likely to result in DDIs. Guideline‐recommended treatments for hepatitis C, hepatitis B, and tuberculosis had the highest proportions of contraindications when combined with ARV regimens, while treatments for hepatitis C, malignancy, and mental health conditions had the highest proportion of combinations potentially causing DDIs requiring dose monitoring or adjustment. Conclusions Non‐ARV use by PWHIV is high and increases with age. Treatment decisions for ageing PWHIV should consider guideline recommendations for comorbidities.
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Affiliation(s)
- C Okoli
- ViiV Healthcare, Brentford, UK
| | - A Schwenk
- North Middlesex University Hospital NHS Trust, London, UK
| | | | - M Myland
- IQVIA Real World Insights, UK & Ireland, London, UK
| | - S Taylor
- Birmingham Heartlands HIV Service, Department of Infection and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Darley
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J Barnes
- Birmingham Heartlands HIV Service, Department of Infection and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Fox
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - F Grimson
- IQVIA Real World Insights, UK & Ireland, London, UK
| | - I Reeves
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - S Munshi
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - A Croucher
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - N Boxall
- IQVIA Real World Insights, UK & Ireland, London, UK
| | - P Benn
- ViiV Healthcare, Brentford, UK
| | - A Paice
- ViiV Healthcare, Brentford, UK
| | | | - S Khoo
- University of Liverpool, Liverpool, UK
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8
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Joachimiak A, Rosenbaum G, Tan K, Chang C, Duke NEC, Kim Y, Michalska K, Nocek B, Osipiuk J, Park SO, Radford M, Bulaon P, Alkire RW, Lazarski K. The Structural Biology Center user program at the Advanced Photon Source. Acta Crystallogr A Found Adv 2017. [DOI: 10.1107/s0108767317096830] [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: 11/10/2022] Open
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9
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Affiliation(s)
- R Ahmad
- Department of Orthopaedics, Weston General Hospital, Weston-Super-Mare, UK
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Affiliation(s)
- R Ahmad
- Department of Orthopaedics, Weston General Hospital, Weston-Super-Mare, UK.
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Ahmad R, Ahmed SMY, Radford M. A Novel Technique for Wound Irrigation. Ann R Coll Surg Engl 2007; 89:727-8. [DOI: 10.1308/rcsann.2007.89.7.727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- R Ahmad
- Department of Orthopaedics and Trauma, Weston General Hospital Weston-super-Mare, UK
| | - SMY Ahmed
- Department of Orthopaedics and Trauma, Weston General Hospital Weston-super-Mare, UK
| | - M Radford
- Department of Orthopaedics and Trauma, Weston General Hospital Weston-super-Mare, UK
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12
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Graff L, Chern C, Turnbull D, Wang Y, Foody J, Werdmann M, Radford M. Physicians' Acute Coronary Syndrome Testing Threshold and Diagnostic Performance. Ann Emerg Med 2005. [DOI: 10.1016/j.annemergmed.2005.06.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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13
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Graff L, Wang Y, Foody J, Meehan T, Tuozzo K, Krumholz H, Radford M. Delay in diagnosis of acute myocardial infarction: Increasingly common, lower quality of care. Ann Emerg Med 2004. [DOI: 10.1016/j.annemergmed.2004.07.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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14
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Graff L, Foody J, Galusha D, Tuozzo K, Meehan T, Radford M. Effect of interhospital transfer patterns on hospitals' quality performance measurement results. Ann Emerg Med 2004. [DOI: 10.1016/j.annemergmed.2004.07.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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15
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Abstract
Bone is a frequent site of tumour metastasis and is the third most common site of metastatic carcinoma. With advances in the use of immunotherapy, hormonal manipulation, chemotherapy and radiation for the palliation of patients with metastatic bone disease, significant improvements in survival, wellbeing and overall quality of life have been achieved.
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Affiliation(s)
- M Radford
- Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD
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16
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Williamson ADB, Radford M. The role of the clinical nurse specialist in pre-assessment and coordination of the care of patients with fractured neck of femur - the Good Hope experience. Anaesthesia 2002. [DOI: 10.1046/j.1365-2044.2002.02899_2.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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Johnston P, Williamson A, Radford M. Emergency surgery in the NHS. Anaesthesia 2001; 56:1204-5. [PMID: 11766676 DOI: 10.1046/j.1365-2044.2001.02369-4.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Rapley EA, Hargrave D, Persinguhe N, Barfoot R, Moore I, Radford M, Stratton MR, Rahman N, Pritchard-Jones K. Case of interstitial 12q deletion in association with Wilms tumor. Am J Med Genet 2001; 104:246-9. [PMID: 11754052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
A 14-month-old boy presenting with Wilms tumor (WT) was found to have a small de novo deletion of the long arm of chromosome 12 (12q11-12q13.11). Microsatellite analysis of this region from constitutional DNA showed that the paternal allele was absent between the markers D12S331 and D12S1713 (inclusive). In the WT there was no evidence of loss of the maternal chromosome. Constitutional chromosome abnormalities can often point to the presence of genes that are important in disease, and the deletion of chromosome 12 in this patient may indicate a gene involved in WT. To determine whether a WT predisposition locus exists at 12q we examined the region in two familial Wilms tumor (FWT) pedigrees unlinked to the known FWT genes on chromosomes 17q (FWT1), 19q (FWT2), and 11p (WT1). In both families WT did not segregate with chromosome 12q markers located within the deletion boundaries.
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Affiliation(s)
- E A Rapley
- Institute of Cancer Research, Section of Cancer Genetics, Haddow Labs, 15 Cotswold Road, Sutton, Surrey, SM6 8RW, UK.
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Johnston P, Williamson A, Radford M. Emergency surgery in the NHS. Anaesthesia 2001. [DOI: 10.1111/j.1365-2044.2001.2369-4.x] [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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20
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Abstract
The requirements for homologous blood transfusion in patients undergoing total knee replacements under tourniquet, before and after the introduction of autologous transfusion of blood collected from wound drains, are compared. In a control population of 93 patients undergoing total knee replacement, 67 required homologous transfusions of two units or more. In 160 patients who were re-transfused with blood from wound drains, only 30 required additional homologous transfusions. Re-transfusion of filtered drained blood reduces the need for homologous bank blood. This avoids the risks associated with donated blood and affords significant cost savings.
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Affiliation(s)
- V K Peter
- Wycombe General Hospital, High Wycombe, Buckinghamshire HP11 2TT, UK.
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Hayes R, Bratzler D, Armour B, Moore L, Murray C, Stevens BR, Radford M, Fitzgerald D, Elward K, Ballard DJ. Comparison of an enhanced versus a written feedback model on the management of Medicare inpatients with venous thrombosis. Jt Comm J Qual Improv 2001; 27:155-68. [PMID: 11242721 DOI: 10.1016/s1070-3241(01)27014-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND A multistate randomized study conducted under the Health Care Financing Administration's (HCFA's) Health Care Quality Improvement Program (HCQIP) offered the opportunity to compare the effect of a written feedback intervention (WFI) with that of an enhanced feedback intervention (EFI) on improving the anticoagulant management of Medicare beneficiaries who present to the hospital with venous thromboembolic disease. METHODS Twenty-nine hospitals in five states were randomly assigned to receive written hospital-specific feedback (WFI) of feedback enhanced by the participation of a trained physician, quality improvement tools, and an Anticoagulant Management of Venous Thrombosis (AMVT) project liaison (EFI). Differences in the performance of five quality indicators between baseline and remeasurement were assessed. Quality managers were interviewed to determine perceptions of project implementation. RESULTS No significant differences in the change from baseline to remeasurement were found between the two intervention groups. Significant improvement in one indicator and significant decline in two indicators were found for one or both groups. Yet 59% of all quality managers perceived the AMVT project as being successful to very successful, and more EFI quality managers perceived success than did WFI managers (71% versus 40%). In the majority of EFI hospitals, physician liaisons played an important role in project implementation. CONCLUSION Study results indicated that the addition of a physician liaison, quality improvement tools, and a project liaison did not provide incremental value to hospital-specific feedback for improving quality of care. Future studies with larger sample sizes, lengthier follow-up periods, and interventions that include more of the elements shown to affect practice behavior change are needed to identify an optimal feedback model for use by external quality management organizations.
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Affiliation(s)
- R Hayes
- Kerr L. White Institute for Health Services Research, USA.
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22
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Graff L, Russell J, Seashore J, Tate J, Elwell A, Prete M, Werdmann M, Maag R, Krivenko C, Radford M. False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery. Acad Emerg Med 2000; 7:1244-55. [PMID: 11073473 DOI: 10.1111/j.1553-2712.2000.tb00470.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To test the hypothesis that physician errors (failure to diagnose appendicitis at initial evaluation) correlate with adverse outcome. The authors also postulated that physician errors would correlate with delays in surgery, delays in surgery would correlate with adverse outcomes, and physician errors would occur on patients with atypical presentations. METHODS This was a retrospective two-arm observational cohort study at 12 acute care hospitals: 1) consecutive patients who had an appendectomy for appendicitis and 2) consecutive emergency department abdominal pain patients. Outcome measures were adverse events (perforation, abscess) and physician diagnostic performance (false-positive decisions, false-negative decisions). RESULTS The appendectomy arm of the study included 1, 026 patients with 110 (10.5%) false-positive decisions (range by hospital 4.7% to 19.5%). Of the 916 patients with appendicitis, 170 (18.6%) false-negative decisions were made (range by hospital 10.6% to 27.8%). Patients who had false-negative decisions had increased risks of perforation (r = 0.59, p = 0.058) and of abscess formation (r = 0.81, p = 0.002). For admitted patients, when the inhospital delay before surgery was >20 hours, the risk of perforation was increased [2.9 odds ratio (OR) 95% CI = 1.8 to 4.8]. The amount of delay from initial physician evaluation until surgery varied with physician diagnostic performance: 7.0 hours (95% CI = 6.7 to 7.4) if the initial physician made the diagnosis, 72.4 hours (95% CI = 51.2 to 93.7) if the initial office physician missed the diagnosis, and 63.1 hours (95% CI = 47.9 to 78.4) if the initial emergency physician missed the diagnosis. Patients whose diagnosis was initially missed by the physician had fewer signs and symptoms of appendicitis than patients whose diagnosis was made initially [appendicitis score 2.0 (95% CI = 1.6 to 2.3) vs 6.5 (95% CI = 6.4 to 6.7)]. Older patients (>41 years old) had more false-negative decisions and a higher risk of perforation or abscess (3.5 OR 95% CI = 2.4 to 5.1). False-positive decisions were made for patients who had signs and symptoms similar to those of appendicitis patients [appendicitis score 5.7 (95% CI = 5.2 to 6.1) vs 6.5 (95% CI = 6.4 to 6.7)]. Female patients had an increased risk of false-positive surgery (2.3 OR 95% CI = 1.5 to 3.4). The abdominal pain arm of the study included 1,118 consecutive patients submitted by eight hospitals, with 44 patients having appendicitis. Hospitals with observation units compared with hospitals without observation units had a higher "rule out appendicitis" evaluation rate [33.7% (95% CI = 27 to 38) vs 24.7% (95% CI = 23 to 27)] and a similar hospital admission rate (27.6% vs 24.7%, p = NS). There was a lower miss-diagnosis rate (15.1% vs 19.4%, p = NS power 0.02), lower perforation rate (19.0% vs 20.6%, p = NS power 0.05), and lower abscess rate (5.6% vs 6.9%, p = NS power 0.06), but these did not reach statistical significance. CONCLUSIONS Errors in physician diagnostic decisions correlated with patient clinical findings, i.e., the missed diagnoses were on appendicitis patients with few clinical findings and unnecessary surgeries were on non-appendicitis patients with clinical findings similar to those of patients with appendicitis. Adverse events (perforation, abscess formation) correlated with physician false-negative decisions.
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Affiliation(s)
- L Graff
- New Britain General Hospital, New Britain, CT 06050, USA.
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23
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Abstract
Sural nerve injury is a complication of Achilles Tendon (TA) rupture. We dissected 30 cadaveric lower limbs to describe the course of the sural nerve in relation to the TA. At the level of insertion of the TA into the calcaneum, the sural nerve was a mean 18.8 mm from the lateral border of the TA. The proximal course of the nerve was towards the midline such that it crossed the lateral border of the TA at a mean distance of 9.8 cm from the calcaneum. The significant individual variation in the position of the sural nerve in relation to the achilles tendon should be borne in mind when placing sutures in the proximal part of the achilles tendon. Percutaneous sutures should not be placed in the lateral half of the TA.
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Affiliation(s)
- J Webb
- Department of Trauma & Orthopedic Surgery, North Bristol NHS Trust, Southmead Hospital, UK.
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25
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Abstract
Sural nerve injury is a complication of Achilles Tendon (TA) rupture. We dissected 30 cadaveric lower limbs to describe the course of the sural nerve in relation to the TA. At the level of insertion of the TA into the calcaneum, the sural nerve was a mean 18.8 mm from the lateral border of the TA. The proximal course of the nerve was towards the midline such that it crossed the lateral border of the TA at a mean distance of 9.8 cm from the calcaneum. The significant individual variation in the position of the sural nerve in relation to the achilles tendon should be borne in mind when placing sutures in the proximal part of the achilles tendon. Percutaneous sutures should not be placed in the lateral half of the TA.
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Affiliation(s)
- J Webb
- Department of Trauma & Orthopedic Surgery, North Bristol NHS Trust, Southmead Hospital, UK.
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26
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Abstract
The launch of the government's new nursing strategy Mating a Difference, DoH (1999), has highlighted the role that nursing will play in the future provision of healthcare in the NHS.
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27
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Radford M. Early diagnosis of child cancer. Practitioner 1999; 243:664-6, 669-70. [PMID: 10715863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Affiliation(s)
- M Radford
- Department of Child Health, Southampton General Hospital
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28
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Radford M. "Unnecessary suffering": the cornerstone of animal protection legislation considered. Crim Law Rev 1999:702-13. [PMID: 11863025] [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] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Causing "unnecessary suffering" has been widely adopted in legislation to define criminal liability in respect of the treatment of animals. This article examines the way in which the term has been interpreted and applied by the courts, and considers its effectiveness in affording animals protection from abuse.
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Affiliation(s)
- M Radford
- School of Law, University of East Anglia
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Abstract
During the 1990s, geographical distancing of clinical areas and nurse education establishments led to breakdowns in communication. This article focuses on how Good Hope Hospital NHS Trust and the University of Central England in Birmingham created a meaningful learning environment for student nurses in the operating theatre using a revised version of Crofts and Taylor's (1996) perioperative placement model. The student evaluation has demonstrated that the quality of placement, teaching and supervision were of a high standard and students felt that their nursing skills had been enriched as a direct result of the placement. This article will also examine the background to student placements in the operating theatre.
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Affiliation(s)
- M Radford
- Good Hope Hospital NHS Trust, Sutton Coldfield, West Midlands
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30
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Brass LM, Krumholz HM, Scinto JD, Mathur D, Radford M. Warfarin use following ischemic stroke among Medicare patients with atrial fibrillation. Arch Intern Med 1998; 158:2093-100. [PMID: 9801175 DOI: 10.1001/archinte.158.19.2093] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Elderly patients with ischemic stroke and atrial fibrillation are at especially increased risk for recurrent stroke. Warfarin sodium is highly effective in reducing this risk. OBJECTIVE To determine the use of warfarin among a population sample of elderly patients with atrial fibrillation hospitalized for ischemic stroke. METHODS The Connecticut Peer Review Organization conducted a chart review of Medicare patients, aged 65 years or older, hospitalized in 1994 with a diagnosis of atrial fibrillation. Patients with a principal diagnosis of acute myocardial infarction or another indication for anticoagulation were excluded. RESULTS Among 635 patients (402 women; 585 white; 218 > or =85 years old; 147 with a new diagnosis of atrial fibrillation), 334 had stroke as a principal diagnosis. Among those discharged alive after a stroke, only 147 (53%) of 278 were prescribed warfarin at discharge. Furthermore, among 130 (47%) of 278 patients not prescribed warfarin at discharge, 81 (62%) of 130 were also not prescribed aspirin. Increased potential benefit (additional vascular risk factors) was not associated with a higher rate of warfarin use. Low risk for anticoagulation (lack of risk factors for bleeding) was associated with a slightly higher rate of warfarin use. Among those with an increased risk of stroke and a low risk for bleeding (ideal candidates), 124 (62%) of 278 were discharged on a regimen of warfarin. CONCLUSION Anticoagulation of elderly stroke patients with atrial fibrillation, even among ideal candidates, is underused. The increased use of warfarin among these patients represents an excellent opportunity for reducing the risk of recurrent stroke in this high-risk population.
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Affiliation(s)
- L M Brass
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, Yale University School of Medicine, Conn 06520-8018, USA.
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Affiliation(s)
- M Radford
- Good Hope Hospital NHS Trust, Sutton Coldfield
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Abstract
BACKGROUND AND PURPOSE Warfarin reduces the rate of stroke among patients with atrial fibrillation. We sought to determine warfarin use within a population sample of elderly patients with atrial fibrillation. METHODS The Connecticut Peer Review Organization conducted a chart review of Medicare patients aged > or = 65 years with a history of atrial fibrillation before a hospitalization during the first 6 months of 1994. RESULTS Among 488 patients (308 women; 457 white; 173 aged > or = 85 years), 38% (184/488) had a relative contraindication to anticoagulation (history of bleeding, dementia, alcohol use, falls, cancer, or the need for nonsteroidal anti-inflammatory drugs). Among the remaining patients (with known atrial fibrillation, but without a contraindication), only 38% (117/304) had been prescribed warfarin. Of those not prescribed warfarin, 63% (117/187) were also not taking aspirin. There were 272 patients with at least one additional vascular risk factor and no contraindication to anticoagulation. Among these patients at moderate to high risk for stroke, anticoagulation had been prescribed in 40% (109/272). Overal, among those not prescribed warfarin, 58% (95/163) were not taking aspirin. Patients admitted with a stroke were more likely to be significantly underanticoagulated (with international normalized ratio < 1.5) (43.5% versus 20.9% for those without stroke; P < .005). Anticoagulation was most effective for those with an international normalized ratio > or = 2.0. CONCLUSIONS Warfarin anticoagulation with atrial fibrillation, even among "ideal" candidates, appears dramatically underutilized. In addition, among those prescribed warfarin, patients are often undertreated. Increased warfarin use among patients with atrial fibrillation represents an excellent opportunity for stroke prevention in the elderly.
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Affiliation(s)
- L M Brass
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn., USA.
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Shankar AG, Ashley S, Radford M, Barrett A, Wright D, Pinkerton CR. Does histology influence outcome in childhood Hodgkin's disease? Results from the United Kingdom Children's Cancer Study Group. J Clin Oncol 1997; 15:2622-30. [PMID: 9215833 DOI: 10.1200/jco.1997.15.7.2622] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Histology has been identified as an important prognostic factor in Hodgkin's disease (HD) in adults. Information regarding the impact of histology on outcome in childhood HD is scarce. This study determines the effect of histology on the overall survival (OS) or progression-free survival (PFS) in a national series of children treated in a standardized manner. PATIENTS AND METHODS The results of treatment of 331 assessable patients, treated between January 1, 1982 and June 30, 1992, in the United Kingdom Children's Cancer Study Group (UKCCSG) Hodgkin's study I were reviewed to evaluate OS, PFS, and deaths according to stage and histology. Treatment was either involved-field radiation alone (stage IA) or chlorambucil, vinblastine, procarbazine, and prednisolone (ChlVPP) chemotherapy with or without mediastinal radiation. All were clinically staged at diagnosis. RESULTS Nodular sclerosing (NS) HD was the most common histologic subtype (155 of 331 patients [47%]) and was uniformly distributed through all stages. Lymphocyte-depletion (LD) HD was extremely uncommon (< 1%). Mixed-cellularity (MC) HD had the highest relapse rate, but this was only significant (P < .05) in stage I patients who received local irradiation alone. There was no other statistically significant difference in OS and PFS between the various histologic subtypes. Multivariate analysis for PFS and OS confirmed that stage was the most important prognostic factor and that histology did not have an effect after stratification by stage. CONCLUSION This study demonstrates that with effective multiagent chemotherapy, histologic subtype does not influence outcome. The high relapse rates in stage I MC subtype indicates that MC HD is biologically aggressive and systemic treatment with or without local irradiation may be indicated. The high relapse rate in stage IV patients appeared to be independent of histology.
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Affiliation(s)
- A G Shankar
- Paediatric Department, Royal Marsden Hospital, Sutton, Surrey, United Kingdom
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Abstract
Gonadal function was assessed in 101 postpubertal subjects after chemotherapy for childhood Hodgkin's disease. All had received ChlVPP (chlorambucil, vinblastine, procarbazine, and prednisolone) chemotherapy alone, with no radiotherapy below the diaphragm. Gonadotropin levels were available in 46 (79.3%) male and 32 (74.4%) female subjects. The mean age at diagnosis in the male cohort was 12.2 years (range 8.2-15.3) and in the females 13.0 years (9.0-15.2). The males and the females were studied at a median of 6 years (range 2.5-11.1) and 4.3 years (range 1.9-11.5) from diagnosis, respectively. Forty-one (89.1%) male subjects had elevated follicle-stimulating hormone (FSH) levels, confirming severe germinal epithelial damage. Germinal epithelial damage was seen in subjects up to 10 years out of therapy. Subtle Leydig cell dysfunction was identified in 24.4% with raised luteinzing hormone (LH) levels. All subjects, however, progressed spontaneously through puberty. Seventeen (53%) women had raised gonadotropin levels, with variable estradiol levels. Of these, 10 subjects presented with symptomatic ovarian failure and 6 received hormone replacement therapy (HRT). Nine women had 11 successful pregnancies, two of whom had previously had symptoms of ovarian failure with one requiring HRT. A much higher prevalence of ovarian failure has been observed, than has previously been considered in the prepubertal and pubertal female following combination chemotherapy. These conclusions have important implications for future counseling, management, and research in this population.
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Affiliation(s)
- E J Mackie
- Department of Paediatric Oncology, The Christie Hospital, NHS Trust, Manchester, United Kingdom
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Massie BM, Fisher SG, Radford M, Deedwania PC, Singh BN, Fletcher RD, Singh SN. Effect of amiodarone on clinical status and left ventricular function in patients with congestive heart failure. CHF-STAT Investigators. Circulation 1996; 93:2128-34. [PMID: 8925581 DOI: 10.1161/01.cir.93.12.2128] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.4] [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: 02/03/2023]
Abstract
BACKGROUND Although trials of amiodarone therapy in patients with congestive heart failure have produced discordant results with regard to effects on survival, most studies have reported a significant rise in left ventricular ejection fraction during long-term therapy. In the present study, we determined whether this increase in ejection fraction is associated with an improvement in the symptoms and/or physical findings of heart failure or a reduction in the number of hospitalizations for heart failure. METHODS AND RESULTS In the Department of Veterans Affairs cooperative study of amiodarone in congestive heart failure, 674 patients with New York Heart Association class II through IV symptoms and ejection fractions of < or = 40% were treated with amiodarone or placebo for a median of 45 months in a randomized, double-blind, placebo-controlled protocol. Clinical assessments and radionuclide ejection fraction were performed at baseline and after 6, 12, and 24 months. Compared with the placebo group, ejection fraction increased more in the amiodarone group at each time point (8.1 +/- 10.2% [mean +/- SD] versus 2.6 +/- 7.9% at 6 months, 8.0 +/- 10.9% versus 2.7 +/- 8.0% at 12 months, and 8.8 +/- 10.1% versus 1.9 +/- 9.4% after 24 months, all P < .001). However, this difference was not associated with greater clinical improvement, lesser diuretic requirements, or fewer hospitalizations for heart failure (11.1% for amiodarone and 13.6% for placebo group; overall relative risk in the amiodarone group, 0.81 [95% CI, 0.56 to 1.10], P = .18). Of note is the trend toward a reduction in the combined end point of hospitalizations and cardiac deaths (relative risk, 0.82 [CI, 0.65 to 1.03], P = .08), which was significant in patients with nonischemic etiology (relative risk, 0.56 [CI, 0.36 to 0.87], P = .01) and absent in the ischemic group (relative risk, 0.95). CONCLUSIONS Although amiodarone therapy resulted in a substantial increase in left ventricular ejection fraction in patients with congestive heart failure, this was not associated with clinical benefit in the population as a whole. The substantial reduction in the combined end point of cardiac death plus hospitalizations for heart failure in the nonischemic group suggests possible benefit in these patients.
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Affiliation(s)
- B M Massie
- Department of Veterans Affairs Cooperative Studies Program, Washington, DC, USA
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Radford M. Wild Mammals (Protection) Act. Vet Rec 1996; 138:287. [PMID: 8711888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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37
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Abstract
This paper describes the results of a questionnaire survey on some aspects of nebulizer use, nebulizer instruction, and features relating to the recognition and management of deteriorating asthma. The study population consisted of 90 children with home nebulizers attending a paediatric asthma clinic, and 200 asthmatic children and 200 asthmatic adults whose nebulizers had been purchased directly from a manufacturer in the U.K. The results suggest that follow-up supervision of the patients who bought their own nebulizers occurred in only approximately 25% of cases. Written information focusing on the management of symptoms was also lacking. Peak flow meters were being under-used. Although the majority (77-100%) of patients were aware of the '4 h rule' for repeat use of bronchodilator therapy at home, there was still some confusion about the acceptable time interval and action to be taken should the dose be required more frequently. Very few (32%) in the nationwide adult group had a crisis action plan should the nebulizer fail to produce relief. This paper recommends that a simple treatment and crisis plan should be included with the purchased nebulizer, highlighting the key areas to be discussed by the patients with the doctor or other medical professionals. Such a package may prevent the occasional disaster that can occur with unsupervised nebulized bronchodilator usage.
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Affiliation(s)
- R K Gregson
- Child Health, University of Southampton, U.K
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38
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Wagner PJ, Phillips W, Radford M, Hornsby JL. Frequent use of medical services. Patient reports of intentions to seek care. Arch Fam Med 1995; 4:594-9; discussion 599. [PMID: 7606296 DOI: 10.1001/archfami.4.7.594] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To examine differences between frequent and infrequent users in decisions to seek medical care based on symptom type and duration of experience of the symptom. DESIGN Retrospective study. SETTING University family practice clinic. PATIENTS Fifty-eight of 130 patients returned the completed instruments, a response rate of 45%. MAIN OUTCOME MEASURES The following two instruments were used: the Intentions to Seek Care questionnaire, which measures intention to see a physician, self-treat, or use medications for 11 different symptoms after three time periods--1 day, 3 days, and 1 week of symptom duration--and the SF-36 Health Survey measure. RESULTS Initial analyses suggested that patients perceive three clusters of symptoms, which we have labeled as serious, mild, and psychological. Scale scores for these groups of symptoms yielded significant reliability and were used in subsequent analyses. Multivariate analysis of variance comparing source of care, symptom duration, and frequent vs infrequent user groups indicated that both user groups are more likely to seek care from physicians for symptoms that are serious. Analysis of mild and psychological symptoms yielded significant three-way interactions, with frequent users more likely than infrequent users to seek care from physicians at a 1-day duration. Such differences disappear by 7 days. Significantly lower scores were obtained on five of the eight SF-36 Health Survey dimensions for the infrequent users. CONCLUSIONS Frequent users are more likely than infrequent users to report that they would seek care for minor symptoms. Infrequent users tend to self-treat for 3 to 7 days, after which time physician advice is sought. Efforts to teach patients optimal timing of use for different symptoms may be an effective intervention.
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Affiliation(s)
- P J Wagner
- Department of Family Medicine, Medical College of Georgia, Augusta, USA
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39
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Abstract
The aim of this study was to look at the current lifestyle of young adult survivors of childhood cancer between the ages of 16 and 30 years to document their achievements and expose any psychosocial problems. Sixty six young adult survivors were contacted and asked if they and their siblings (16-30 years) would take part in a lifestyle study; 48 patients and 38 sibling controls were interviewed. This took the form of a structured lifestyle questionnaire, a self esteem questionnaire (Oxford Psychologists Press), and an unstructured interview. Fifty five per cent of patients achieved five or more A-C grades at 'O' level/GCSE compared with 62% of siblings and a national average of 30%. Despite that these patients were significantly less likely to go on to higher education than their siblings. The two groups were equally employable and earning similar salaries. There were three cases of known employer prejudice. A slightly higher percentage of patients than siblings had their driving licence. Seventeen patients felt their appearance had changed and eight felt that they had a residual physical mobility problem. Both groups were socially active and equally likely to partake in competitive sports. There was no overall difference in the self esteem of the two groups. In general the survivors of childhood cancer were coping well in their young adult life and achieving the same lifestyle goals as their siblings. However, significant problems have been identified.
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Affiliation(s)
- S E Evans
- Department of Child Health, University of Southampton, Southampton General Hospital
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40
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Abstract
Childhood Hodgkin's disease has a high cure rate but second cancers are common, related to treatment and perhaps genetic predisposition. The glycophorin A (GPA) mutation assay measures the frequency of NO and NN mutant erythrocytes of MN blood-group heterozygous individuals. Mutant frequencies in Hodgkin's disease patients were compared with controls. No significant difference from controls was found pretreatment or in patients treated with radiotherapy only. Patients who received chemotherapy had a significantly increased frequency (total mutation frequency per 10(6) cells: 31 vs 11, p < 0.001), which may be relevant to their known increased risk of secondary leukaemia.
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Affiliation(s)
- M G Mott
- Institute of Child Health, Royal Hospital for Sick Children, Bristol, UK
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41
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Morland B, Cox G, Randall C, Ramsay A, Radford M. Synovial sarcoma of the larynx in a child: case report and histological appearances. Med Pediatr Oncol 1994; 23:64-8. [PMID: 8177148 DOI: 10.1002/mpo.2950230112] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Synovial sarcoma of the larynx is extremely rare having been reported only six times previously in the literature. We add another case report, which to our knowledge is the first recorded case in a child. We discuss the alternative approach of combination chemotherapy and radiotherapy which in this case led to a remission lasting about 3 years. The immunohistological and ultrastructural characteristics of the tumour are also presented.
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Affiliation(s)
- B Morland
- Department of Paediatric Oncology, Birmingham Children's Hospital, United Kingdom
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42
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MacKenzie CA, Tsanakas J, Tabachnik E, Radford M, Berdel D, Götz MH, Parker C. An open study to assess the long-term safety of fluticasone propionate in asthmatic children. International Study Group. Br J Clin Pract 1994; 48:15-8. [PMID: 8179974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This study was conducted to assess the long-term safety of fluticasone propionate 50 micrograms twice daily (100 micrograms/day) or 100 micrograms twice daily (200 micrograms/day) administered via a dry powder inhaler in children aged 4-17 years with moderately severe asthma. A total of 257 patients received open treatment for 12 months. Of these, 110 had not received treatment with fluticasone propionate in any prior study. The remaining 147 patients had completed one of two previous short-term inhaled fluticasone propionate studies. In all, 132 patients (51%) reported 273 adverse events, the pattern of which was as expected in an atopic population with asthma; only 26 (10%) of these reports were considered either certainly, probably or possibly related to study treatment. The events most commonly reported either as a single or multiple diagnosis were: asthma and related events (25%), upper respiratory tract infection (13%), and rhinitis (6%). For most patients who reported a worsening of asthma, additional therapy was all that was required to control symptoms, and they continued in the study. There was a low incidence (2%) of pharmacologically predictable adverse events. Eight patients (3%) withdrew from the study because of an adverse event, five of which events (one each of hypertension, hoarseness and asthma and two of oral candidiasis) were recorded as being possibly or probably drug-related. Sixteen adverse events reported by 15 patients (6%) were classified as serious but none was considered to be related to the study drug. Of these reports 10 ( patients; 4%) were exacerbations of asthma requiring hospital admission; the other six adverse events were unrelated to asthma.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- C A MacKenzie
- University of Sheffield Children's Hospital, Western Bank, UK
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43
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Zeitlin S, Wood P, Evans A, Radford M. Overnight urine growth hormone, cortisol and adenosine 3' 5' cyclic monophosphate excretion in children with chronic asthma treated with inhaled beclomethasone dipropionate. Respir Med 1993; 87:445-8. [PMID: 8210614 DOI: 10.1016/0954-6111(93)90071-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [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: 01/29/2023]
Abstract
Overnight urine samples were obtained from 34 asthmatic children, 24 of whom were receiving inhaled beclomethasone dipropionate (BDP), and 30 controls. The urine volume of the children receiving inhaled steroids was significantly greater than that of the other asthmatic children and of the controls (P < 0.05). Urine growth hormone was within the normal range for all of the subjects and there was no demonstrable relationship between urine growth hormone and height or height standard deviation score. Urine steroid output was significantly reduced in the BDP receiving group when the results were expressed in U l-1 but there was no difference between the groups when the results were expressed per specimen. Urine adenosine 3' 5' cyclic monophosphate (cAMP) results were similar for all groups. We conclude that use of BDP increases overnight urine volume but, in our study, does not appear to influence the output of urine cortisol. Urine free cortisol measurements may not be a very sensitive tool for the detection of small changes in endogenous steroid production. The use of BDP does not adversely affect the output of urine growth hormone.
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Affiliation(s)
- S Zeitlin
- Department of Child Health, Southampton General Hospital, U.K
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44
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Gustafsson P, Tsanakas J, Gold M, Primhak R, Radford M, Gillies E. Comparison of the efficacy and safety of inhaled fluticasone propionate 200 micrograms/day with inhaled beclomethasone dipropionate 400 micrograms/day in mild and moderate asthma. Arch Dis Child 1993; 69:206-11. [PMID: 8215522 PMCID: PMC1029458 DOI: 10.1136/adc.69.2.206] [Citation(s) in RCA: 88] [Impact Index Per Article: 2.8] [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: 01/29/2023]
Abstract
This study was designed to compare the efficacy and safety of a new inhaled corticosteroid, fluticasone propionate at a total daily dose of 200 micrograms, with beclomethasone dipropionate 400 micrograms/day in childhood asthma. A total of 398 asthmatic children (aged 4-19 years) were randomised to receive either fluticasone propionate 200 micrograms daily or beclomethasone dipropionate 400 micrograms daily for six weeks inhaled via a spacer device from a metered dose inhaler. During the study the patients recorded morning and evening peak expiratory flow rate (PEFR), symptom scores, and use of beta 2 agonist rescue medication. In addition, clinic visit PEFR and forced expiratory volume in one second were measured. Safety was assessed by recording all adverse events and by performing routine biochemistry and haematology screens including plasma cortisol concentration before and after treatment. For the purposes of analysis the diary card data were grouped into three periods: week 3 (days 15-21), week 6 (days 36-42), and weeks 1-6 (days 1-42). The results showed no significant difference between treatments on most efficacy parameters. However, there were significant differences in changes from baseline in favour of fluticasone propionate for % predicted morning PEFR both at week 3 (fluticasone propionate 6.1%, beclomethasone dipropionate 3.9%) and at week 6 (fluticasone propionate 8.3%, beclomethasone dipropionate 5. 9%) and % predicted evening PEFR at week 6 (fluticasone propionate 7.3%, beclomethasone dipropionate 4.9% and over weeks 1-6 (fluticasone propionate 5.5%, beclomethasone dipropionate 3.6%. Comparison between groups showed that the group receiving fluticasone propionate had a lower % of days with symptom-free exercise at week 6 (fluticasone propionate 87%, beclomethasone dipropionate 81%) and % days without rescue medication at week 6 (fluticasone propionate 87%, beclomethasone dipropionate 80%) and over weeks 1-6 (fluticasone propionate 80%, beclomethasone dipropionate 73%). Except for a higher incidence of sore throat in the fluticasone propionate group, the two treatments did not differ with regard to safety. There was no evidence of adrenal suppression with either treatment. In conclusion, fluticasone propionate 200 microgram daily ws at least as effective and as well tolerated as beclomethasone dipropionate 400 microgram daily in childhood asthma.
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Affiliation(s)
- P Gustafsson
- Department of Paediatrics, University Hospital, Linkoping, Sweden
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45
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Abstract
The importance of second malignant neoplasms following successful treatment of childhood malignancy is of concern to all professionals involved with the care of these patients. We present an 18 year old patient with a squamous cell carcinoma of his lower lip following prolonged treatment for acute lymphoblastic leukaemia in childhood. The rarity of this tumor in this age group and the aetiological factors involved in developing the second malignancy are discussed.
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Affiliation(s)
- B J Morland
- Department of Child Health, Southampton General Hospital, England
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46
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Abstract
In order to determine whether or not there was a relationship between disorders of growth in children suffering from asthma and either increased resting energy expenditure or inadequate energy intake, a group of 34 children suffering from perennial symptoms were studied. A control group matched with the asthmatic children for sex and fat free mass were similarly studied. The children kept seven day records of weighed food intake. Basal metabolic rate was measured on one occasion in the fasted state by means of indirect calorimetry using the ventilated hood technique. The asthmatic children kept a 28 day record of peak expiratory flow rates, asthma symptoms, and medication usage. The asthmatic children expended significantly more energy at rest than their matched controls in absolute terms (14%). There was no correlation between height or height SD score and any parameter of energy balance. The causes of these finding are as yet speculative.
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Affiliation(s)
- S R Zeitlin
- Department of Child Health, Southampton General Hospital
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47
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O'Brien ME, Pinkerton CR, Kingston J, Mott M, Tait D, Meller S, Radford M, Malpas J, McElwain TJ. 'VEEP' in children with Hodgkin's disease--a regimen to decrease late sequelae. Br J Cancer 1992; 65:756-60. [PMID: 1586603 PMCID: PMC1977393 DOI: 10.1038/bjc.1992.159] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In an attempt to decrease the risk of second malignancies and future infertility in children with Hodgkin's disease (HD) while retaining acceptable remission rates, an anthracycline based regimen containing no alkylating agent has been devised. VEEP contains vincristine, epirubicin, etoposide and prednisolone given at 3 weekly intervals. Forty-four patients, aged 2-15 years, have been treated: ten relapsed patients and 34 previously untreated with chemotherapy (including three relapsed stage I treated initially with radiotherapy). The median follow up for all patients is 25 months (range 6-52 months). The response rate in previously treated patients was 80% (95% CI 44-97%) and five remain alive in remission. The response rate in untreated patients was 88% (95% CI 72-97%) with 62% CR + CR(u) (uncertain/unconfirmed) (95% CI 44-77%). Of four patients who had a final response of CR(u) three have relapsed at 9, 16 and 38 months. Two of the children in CR have relapsed at 6 and 16 months. The relapse free rate at 3 years is 67% (95% CI 17-82%). In this pilot study the event free survival appears somewhat poorer than conventional combinations and further follow up is required to confirm the salvagability of relapsed patients.
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48
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Lorber BJ, Freeman SB, Hassold T, Ragab AH, Vega RA, Cockwell AE, Jacobs PA, Radford M, Doyle J, Dubé ID. Characterization and molecular analysis of nondisjunction in 18 cases of trisomy 21 and leukemia. Genes Chromosomes Cancer 1992; 4:222-7. [PMID: 1382563 DOI: 10.1002/gcc.2870040306] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
We recently began a cytogenetic and molecular study of nondisjunction in leukemic Down syndrome individuals to determine whether the mechanism by which the extra chromosome 21 originates predisposes the individual to leukemia. In the present report, we summarize our observations on 18 patients with trisomy 21 and acute or transient leukemia, including 11 patients with acute lymphocytic leukemia, three with acute myeloid leukemia, one with B-cell lymphoma, one with acute megakaryoblastic leukemia, and two with transient leukemia. Results of DNA marker studies of the parental origin of the extra chromosome 21 indicated that 16 of the 18 cases (89%) were maternally derived, a percentage similar to that seen among nonleukemic Down syndrome patients. We noted that most leukemic Down syndrome patients had one locus or more in which parental heterozygosity was maintained in the trisomic individual, indicating a meiotic rather than a mitotic origin for the trisomy.
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Affiliation(s)
- B J Lorber
- Emory University, Atlanta, Georgia 30322
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49
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Nakane Y, Ohta Y, Radford M, Yan H, Wang X, Lee HY, Min SK, Michitsuji S, Ohtsuka T. Comparative study of affective disorders in three Asian countries. II. Differences in prevalence rates and symptom presentation. Acta Psychiatr Scand 1991; 84:313-9. [PMID: 1746279 DOI: 10.1111/j.1600-0447.1991.tb03151.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.0] [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: 12/28/2022]
Abstract
This study used standardized diagnostic criteria and method to investigate both prevalence rates and nature of symptoms of depressive disorders in three Asian centres--Nagasaki, Shanghai and Seoul. Of the patients who visited a psychiatric clinic in each of the 3 centres for the first time, over 20% suffered from depression. Unlike previous reported prevalence rates for Asian countries, these results suggest that rates in Asia may not be much lower than those reported in Western countries. Although prevalence rates of depression were similar in all 3 centres, differences in symptoms were noted.
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Affiliation(s)
- Y Nakane
- Department of Neuropsychiatry, Nagasaki University School of Medicine, Japan
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50
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