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Campbell MJ, Beenken KE, Ramirez AM, Smeltzer MS. Increased production of aureolysin and staphopain A is a primary determinant of the reduced virulence of Staphylococcus aureus sarA mutants in osteomyelitis. mBio 2024; 15:e0338323. [PMID: 38415646 PMCID: PMC11005355 DOI: 10.1128/mbio.03383-23] [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: 12/12/2023] [Accepted: 02/09/2024] [Indexed: 02/29/2024] Open
Abstract
We previously demonstrated that mutation of sarA in Staphylococcus aureus limits biofilm formation, cytotoxicity for osteoblasts and osteoclasts, and virulence in osteomyelitis, and that all of these phenotypes can be attributed to the increased production of extracellular proteases. Here we extend these studies to assess the individual importance of these proteases alone and in combination with each other using the methicillin-resistant USA300 strain LAC, the methicillin-susceptible USA200 strain UAMS-1, and isogenic sarA mutants that were also unable to produce aureolysin (Aur), staphopain A (ScpA), staphylococcal serine protease A (subsp.), staphopain B (SspB), and the staphylococcal serine protease-like proteins A-F (SplA-F). Biofilm formation was restored in LAC and UAMS-1 sarA mutants by subsequent mutation of aur and scpA, while mutation of aur had the greatest impact on cytotoxicity to mammalian cells, particularly with conditioned medium (CM) from the more cytotoxic strain LAC. However, SDS-PAGE and western blot analysis of CM confirmed that mutation of sspAB was also required to mimic the phenotype of sarA mutants unable to produce any extracellular proteases. Nevertheless, in a murine model of post-traumatic osteomyelitis, mutation of aur and scpA had the greatest impact on restoring the virulence of LAC and UAMS-1 sarA mutants, with concurrent mutation of sspAB and the spl operon having relatively little effect. These results demonstrate that the increased production of Aur and ScpA in combination with each other is a primary determinant of the reduced virulence of S. aureus sarA mutants in diverse clinical isolates including both methicillin-resistant and methicillin-susceptible strains.IMPORTANCEPrevious work established that SarA plays a primary role in limiting the production of extracellular proteases to prevent them from limiting the abundance of S. aureus virulence factors. Eliminating the production of all 10 extracellular proteases in the methicillin-resistant strain LAC has also been shown to enhance virulence in a murine sepsis model, and this has been attributed to the specific proteases Aur and ScpA. The importance of this work lies in our demonstration that the increased production of these same proteases largely accounts for the decreased virulence of sarA mutants in a murine model of post-traumatic osteomyelitis not only in LAC but also in the methicillin-susceptible human osteomyelitis isolate UAMS-1. This confirms that sarA-mediated repression of Aur and ScpA production plays a critical role in the posttranslational regulation of S. aureus virulence factors in diverse clinical isolates and diverse forms of S. aureus infection.
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Affiliation(s)
- Mara J. Campbell
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Karen E. Beenken
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Aura M. Ramirez
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mark S. Smeltzer
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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2
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Campbell MJ, Beenken KE, Spencer HJ, Jayana B, Hester H, Sahukhal GS, Elasri MO, Smeltzer MS. Comparative evaluation of small molecules reported to be inhibitors of Staphylococcus aureus biofilm formation. Microbiol Spectr 2024; 12:e0314723. [PMID: 38059629 PMCID: PMC10782960 DOI: 10.1128/spectrum.03147-23] [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: 08/21/2023] [Accepted: 11/09/2023] [Indexed: 12/08/2023] Open
Abstract
IMPORTANCE Because biofilm formation is such a problematic feature of Staphylococcus aureus infections, much effort has been put into identifying biofilm inhibitors. However, the results observed with these compounds are often reported in isolation, and the methods used to assess biofilm formation vary between labs, making it impossible to assess relative efficacy and prioritize among these putative inhibitors for further study. The studies we report address this issue by directly comparing putative biofilm inhibitors using a consistent in vitro assay. This assay was previously shown to maximize biofilm formation, and the results observed with this assay have been proven to be relevant in vivo. Of the 19 compounds compared using this method, many had no impact on biofilm formation under these conditions. Indeed, only one proved effective at limiting biofilm formation without also inhibiting growth.
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Affiliation(s)
- Mara J. Campbell
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Karen E. Beenken
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Horace J. Spencer
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Bina Jayana
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Hana Hester
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gyan S. Sahukhal
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mohamed O. Elasri
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mark S. Smeltzer
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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3
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Campbell MJ, Beenken KE, Ramirez AM, Smeltzer MS. The major role of sarA in limiting Staphylococcus aureus extracellular protease production in vitro is correlated with decreased virulence in diverse clinical isolates in osteomyelitis. Virulence 2023; 14:2175496. [PMID: 36748843 PMCID: PMC9928472 DOI: 10.1080/21505594.2023.2175496] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
We previously demonstrated that MgrA, SarA, SarR, SarS, SarZ, and Rot bind at least three of the four promoters associated with genes encoding primary extracellular proteases in Staphylococcus aureus (Aur, ScpA, SspA/SspB, SplA-F). We also showed that mutation of sarA results in a greater increase in protease production, and decrease in biofilm formation, than mutation of the loci encoding any of these other proteins. However, these conclusions were based on in vitro studies. Thus, the goal of the experiments reported here was to determine the relative impact of the regulatory loci encoding these proteins in vivo. To this end, we compared the virulence of mgrA, sarA, sarR, sarS, sarZ, and rot mutants in a murine osteomyelitis model. Mutants were generated in the methicillin-resistant USA300 strain LAC and the methicillin-sensitive USA200 strain UAMS-1, which was isolated directly from the bone of an osteomyelitis patient during surgical debridement. Mutation of mgrA and rot limited virulence to a statistically significant extent in UAMS-1, but not in LAC, while the sarA mutant exhibited reduced virulence in both strains. The reduced virulence of the sarA mutant was correlated with reduced cytotoxicity for osteoblasts and osteoclasts, reduced biofilm formation, and reduced sensitivity to the antimicrobial peptide indolicidin, all of which were directly attributable to increased protease production in both LAC and UAMS-1. These results illustrate the importance of considering diverse clinical isolates when evaluating the impact of regulatory mutations on virulence and demonstrate the significance of SarA in limiting protease production in vivo in S. aureus.
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Affiliation(s)
- Mara J. Campbell
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Karen E. Beenken
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Aura M. Ramirez
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Im KW, Huppert LA, Malevanchik L, Rugo HS, Combes AJ, Campbell MJ, Krummel MF, Melisko ME. High-dimensional immune cell profiling of cerebrospinal fluid from patients with metastatic breast cancer and leptomeningeal disease. NPJ Breast Cancer 2023; 9:22. [PMID: 37029150 PMCID: PMC10082042 DOI: 10.1038/s41523-023-00526-1] [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] [Received: 11/09/2022] [Accepted: 03/03/2023] [Indexed: 04/09/2023] Open
Abstract
Leptomeningeal disease (LMD) is a devastating complication of metastatic breast cancer (MBC). In this non-therapeutic study, we enrolled 12 patients with MBC and known or suspected LMD who were undergoing a lumbar puncture as part of clinical care and collected extra cerebrospinal fluid (CSF) and a paired blood sample from each patient at a single time point. Of the 12 patients, 7 patients are confirmed to have LMD based on positive cytology and/or convincing MRI imaging (LMDpos), and 5 patients are deemed not to have LMD based on similar criteria (LMDneg). Using high-dimensional, multiplexed flow cytometry, we profile and compare the CSF and peripheral blood mononuclear cell (PBMCs) immune populations between patients with LMD and those without. Patients with LMD observe a lower overall frequency of CD45+ cells (29.51% vs. 51.12%, p < 0.05), lower frequencies of CD8+ T cells (12.03% vs. 30.40%, p < 0.01), and higher frequency of Tregs than patients without LMD. Interestingly, the frequency of partially exhausted CD8+ T cells (CD38hiTIM3lo) is ~6.5-fold higher among patients with LMD vs. those without (2.99% vs. 0.44%, p < 0.05). Taken together, these data suggest that patients with LMD may have lower overall immune infiltrates than patients without LMD, suggesting a more permissive CSF immune microenvironment but a higher frequency of partially exhausted CD8+ T cells, which may offer an important therapeutic target.
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Affiliation(s)
- K W Im
- Department of Pathology and ImmunoX Initiative, University of California at San Francisco, San Francisco, CA, 94143, USA.
- UCSF CoLabs, University of California San Francisco, San Francisco, CA, USA.
| | - L A Huppert
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - L Malevanchik
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - H S Rugo
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - A J Combes
- Department of Pathology and ImmunoX Initiative, University of California at San Francisco, San Francisco, CA, 94143, USA
- UCSF CoLabs, University of California San Francisco, San Francisco, CA, USA
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - M J Campbell
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - M F Krummel
- Department of Pathology and ImmunoX Initiative, University of California at San Francisco, San Francisco, CA, 94143, USA
| | - M E Melisko
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Vasconcelos AL, Campbell MJ, Barratt CLR, Gellatly SA. Do studies published in two leading reproduction journals between 2011 and 2020 demonstrate that they followed WHO5 recommendations for basic semen analysis? Hum Reprod 2022; 37:2255-2263. [PMID: 35947767 PMCID: PMC9527455 DOI: 10.1093/humrep/deac173] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/06/2022] [Indexed: 11/15/2022] Open
Abstract
STUDY QUESTION Do publications that involve the interpretation of the results of a basic semen analysis, published in Human Reproduction and Fertility & Sterility between 2011 and 2020, give sufficient evidence in their methodology to demonstrate that they followed the technical methods recommended in the fifth edition of the World Health Organization (WHO) laboratory manual, entitled WHO Laboratory Manual for the Examination and Processing of Human Semen (WHO5)? SUMMARY ANSWER Evidence of methodological agreement of studies with the WHO5 recommendations was low, despite 70% of papers stating that they followed WHO5 recommendations. WHAT IS KNOWN ALREADY A basic semen analysis is currently an integral part of infertility investigations of the male, but method standardization in laboratories remains an issue. The different editions of the WHO manual for the basic semen analysis (WHO1-6) have attempted to address this by providing increasingly rigorous methodological protocols to reduce experimental error. However, to what extent these methods are followed by studies that involve the interpretation of the results of basic semen analysis remains unknown. STUDY DESIGN, SIZE, DURATION A survey of the technical methods used to perform a basic semen analysis was conducted on studies published in two leading reproduction journals (Human Reproduction and Fertility & Sterility) between 2011 and 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS The literature search was performed on the electronic databases PUBMED and MEDLINE Ovid between January 2021 and March 2021. The MeSH terms included in the search were 'sperm concentration' OR 'sperm motility' OR 'sperm morphology' OR 'sperm vitality' OR 'male fertility' AND 'human spermatozoa' NOT 'animals'. A total of 122 studies were available for analysis. MAIN RESULTS AND THE ROLE OF CHANCE In total, 70% of the studies cited WHO5 in their methods section. Of the remaining studies, 10% cited the fourth edition of the WHO laboratory manual (WHO4), 7% cited both WHO4 and WHO5, 1% cited the third edition of the WHO laboratory manual (WHO3), and 12% did not cite the WHO at all. Overall methodological agreement with WHO5 recommendations was poor, with the main reason for this lack of agreement being that the research studies did not disclose specific details of the technical methods and equipment used. LIMITATIONS, REASONS FOR CAUTION In the case of studies that did not disclose any specific technical methods that they used, we did not attempt to contact these authors and so were unable to confirm the agreement between their technical methods and WHO5 recommendations. WIDER IMPLICATIONS OF THE FINDINGS Our findings suggest there is an urgent need to develop strategies to address standardization in reporting the results of a semen analysis for publication. This is particularly timely given the recent publication of WHO6 and ISO standard 23162 for the basic examination of human semen. STUDY FUNDING/COMPETING INTEREST(S) There was no funding for this project. C.L.R.B., as an employee of the University of Dundee, serves on the Scientific Advisory board of ExSeed Health (from October 2021, financial compensation to the University of Dundee) and is a scientific consultant for Exscientia (from September 2021, financial compensation to the University of Dundee). C.L.R.B. has previously received a fee from Cooper Surgical for lectures on scientific research methods outside the submitted work (2020) and Ferring for a lecture on male reproductive health (2021). C.L.R.B. is Editor for RBMO. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- A L Vasconcelos
- Division of Systems Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - M J Campbell
- Division of Systems Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - C L R Barratt
- Division of Systems Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - S A Gellatly
- Division of Systems Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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6
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Pinsker BL, Serfas JD, Awerbach JD, Dizon S, Campbell MJ, Krasuski RA. Cardiac MRI risk factors predict atrial arrhythmia development in repaired tetralogy of Fallot patients. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Introduction
Tetralogy of Fallot (TOF) patients with atrial arrhythmias (AA) experience greater morbidity and mortality than do their arrhythmia-free counterparts. Cardiac MRI (cMRI) has proven useful in elucidating risk factors for arrhythmia development in this population, but more work needs to be done to assess the efficacy of predicting AA onset.
Purpose
To evaluate demographic and clinical metrics, including those routinely assessed on cMRI, that predict AA onset in repaired TOF.
Methods
175 repaired TOF patients ≥18 years of age and without prior AA undergoing initial cMRI between 2003 and 2020 were identified from a tertiary U.S. hospital database. Subsequent development of AA (specifically atrial fibrillation, atrial flutter, and atrial tachycardia) was evaluated by chart review and device checks (if present). Kaplan-Meier analysis was used to assess arrhythmia-free survival based on cMRI characteristics, and log-rank test used to compare differences in survival curves. Cutoff values for Kaplan-Meier analysis were the mean value (for the respective variable being measured) of our cohort at the time of their initial cMRI.
Results
Over a median follow-up of 3.3 years, 30 patients (17%) developed AA, including 16 with atrial fibrillation (53%), 20 with atrial flutter (67%), and 2 with atrial tachycardia (7%). Age at cMRI (p<0.01), history of hypertension (p=0.01), and time from birth to complete TOF repair (p<0.05) predicted AA. cMRI predictors included indexed right ventricular (RV) end diastolic and systolic volumes (both p<0.01), as well as indexed right atrial (RA) volume (p<0.05) and pulmonic regurgitation (PR) fraction (p<0.05). Indexed RV and RA volumes but not left sided chamber volumes predicted the development of atrial fibrillation. All Kaplan-Meier survival distributions were significantly different with the exception of those for right atrial volumes.
Conclusions
Our study suggests that RA and RV volumes may play a valuable role in predicting atrial arrhythmia onset in the repaired TOF population. Disease progression in a predominantly right-sided heart disease may play a role in predicting the onset of both “right sided” arrhythmias such as atrial flutter, as well as “left sided” arrhythmias such as atrial fibrillation. Additionally, the increased AA burden in patients with mild RV dilation seen in our study may suggest a potential benefit to early pulmonic valve replacement in this patient group.
Funding Acknowledgement
Type of funding sources: None. Clinical and cMRI CharacteristicsKaplan-Meier Survival Analysis
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Affiliation(s)
- B L Pinsker
- Duke University, Durham, United States of America
| | - J D Serfas
- Duke University, Durham, United States of America
| | - J D Awerbach
- Phoenix Children's Hospital, Phoenix, United States of America
| | - S Dizon
- Duke University, Durham, United States of America
| | - M J Campbell
- Duke University, Durham, United States of America
| | - R A Krasuski
- Duke University, Durham, United States of America
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7
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Campbell MJ, Sucquart IE, Whittaker A, Sanganee HJ, Barratt CLR, Martins da Silva SJ. Myeloperoxidase inhibitor AZD5904 enhances human sperm function in vitro. Hum Reprod 2021; 36:560-570. [PMID: 33393586 DOI: 10.1093/humrep/deaa328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/02/2020] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Does AZD5904, a myeloperoxidase inhibitor (MPOi), have any effect on human sperm function in vitro? SUMMARY ANSWER AZD5904 improves sperm function in an in vitro model of oxidative stress (OS) and potentially offers a novel treatment approach for male infertility. WHAT IS KNOWN ALREADY Male infertility is an underlying or contributory cause in half of all couples experiencing difficulties conceiving, yet there is currently no effective treatment or cure. OS is a common pathology in a significant proportion of infertile men. It can negatively affect sperm motility and the ability to fertilize a mature oocyte, as well as DNA integrity, and therefore represents an attractive target for therapeutic intervention. STUDY DESIGN, SIZE, DURATION This study included population-based samples from men (23-50 years) attending Ninewells Assisted Conception Unit, Dundee for diagnostic semen analysis, July 2017-September 2018. Semen samples (n = 47) from 45 patients were used. PARTICIPANTS/MATERIALS, SETTING, METHODS Neutrophils activated using zymosan were incubated with prepared human spermatozoa for 2 h (T2) and 24 h (T24) to create an in vitro model of OS. Parallel samples were co-incubated with AZD5904, an MPOi, to examine its effects. Sperm motility was assessed by computer-assisted sperm analysis at T2 and T24. Functional motility was assessed by sperm penetration assay. Statistical analysis was performed using GraphPad Prism. MAIN RESULTS AND THE ROLE OF CHANCE There was no significant difference in total or progressive sperm motility between any treatment and control groups at T2 or T24. Nonetheless, significant positive effects on sperm function were observed with AZD5904, with 16/45 (35.6%) samples (with both normal and abnormal baseline semen analysis characteristics) displaying a ≥20% increase in sperm penetrated through viscous media (P < 0.003). LIMITATIONS, REASONS FOR CAUTION This was an in vitro study. WIDER IMPLICATIONS OF THE FINDINGS Treatment with AZD5904 resulted in significant increased sperm penetration in one of three samples treated, which is likely to represent improvement in sperm function required for fertilization. We are now planning a clinical trial to validate these results and hope that this could represent a new treatment for male infertility. STUDY FUNDING/COMPETING INTEREST(S) AZD5904 was shared through the AstraZeneca Open Innovation program. The study was funded by AstraZeneca and sponsored by the University of Dundee. Additional funding was provided by Chief Scientist Office/NHS Research Scotland (S.J.M.d.S.). A.W. and H.J.S. are both full time employees of AstraZeneca. A.W. and H.J.S. are inventors on a patent filed by AstraZeneca titled MPOi for use in medicine which includes MPOi for use in the treatment of male infertility (WO 2019/016074 Al). S.J.M.d.S. is Associate Editor of Human Reproduction and Editorial Board member of Reproduction & Fertility. C.L.R.B. is Editor of RBMO and has received lecturing fees from Merck and Ferring and is on the Scientific Advisory Panel for Ohana BioSciences. C.L.R.B. was chair of the World Health Organization Expert Synthesis Group on Diagnosis of Male infertility (2012-2016). C.L.R.B. has a patent WO2013054111 A1 issued. The other authors declare no conflict of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- M J Campbell
- Reproductive Medicine Research Group, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - I E Sucquart
- Reproductive Medicine Research Group, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - A Whittaker
- Emerging Innovations Unit, Discovery Sciences, R&D, AstraZeneca, Cambridge, UK
| | - H J Sanganee
- Emerging Innovations Unit, Discovery Sciences, R&D, AstraZeneca, Cambridge, UK
| | - C L R Barratt
- Reproductive Medicine Research Group, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - S J Martins da Silva
- Reproductive Medicine Research Group, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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Bernjak A, Novodvorsky P, Chow E, Iqbal A, Sellors L, Williams S, Fawdry RA, Marques JLB, Jacques RM, Campbell MJ, Sheridan PJ, Heller SR. Cardiac arrhythmias and electrophysiologic responses during spontaneous hyperglycaemia in adults with type 1 diabetes mellitus. Diabetes Metab 2021; 47:101237. [PMID: 33647473 DOI: 10.1016/j.diabet.2021.101237] [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] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 12/21/2020] [Accepted: 02/08/2021] [Indexed: 01/19/2023]
Abstract
AIM We examined the effect of spontaneous hyperglycaemia in adults with type 1 diabetes mellitus (T1DM) and without history of cardiovascular disease on heart rate variability (HRV), cardiac repolarisation and incidence of cardiac arrhythmias. METHODS Thirty-seven individuals with T1DM (age 17-50 years, 19 males, mean duration of diabetes 19.3 SD(9.6) years) underwent 96 h of simultaneous ambulatory 12-lead Holter ECG and blinded continuous interstitial glucose (IG) monitoring (CGM). HRV, QT interval and cardiac repolarisation were assessed during hyperglycaemia (IG ≥ 15 mmol/l) and compared with matched euglycaemia (IG 5-10 mmol/l) on a different day, separately during the day and night. Rates of arrhythmias were assessed by calculating incidence rate differences. RESULTS Simultaneous ECG and CGM data were recorded for 2395 hours. During daytime hyperglycaemia vs euglycaemia the mean QTc interval duration was 404 SD(21)ms vs 407 SD(20)ms, P = 0.263. T-peak to T-end interval duration corrected for heart rate (TpTendc) shortened: 74.8 SD(16.1)ms vs 79.0 SD(14.8)ms, P = 0.033 and T-wave symmetry increased: 1.62 SD(0.33) vs 1.50 SD(0.39), P = 0.02. During night-time hyperglycaemia vs euglycaemia, the mean QTc interval duration was 401 SD(26)ms vs 404 SD(27)ms, P = 0.13 and TpTend shortened: 62.4 SD(12.0)ms vs 67.1 SD(11.8)ms, P = 0.003. The number of cardiac arrhythmias was low and confined to bradycardia and isolated ectopic beats. A considerable inter-subject and diurnal variability was observed. CONCLUSIONS Hyperglycaemia in individuals with T1DM without known cardiovascular disease was not associated with clinically important cardiac arrhythmias.
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Affiliation(s)
- A Bernjak
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, United Kingdom; INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - P Novodvorsky
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - E Chow
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - A Iqbal
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - L Sellors
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - S Williams
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - R A Fawdry
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - J L B Marques
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - R M Jacques
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - M J Campbell
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - P J Sheridan
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - S R Heller
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom.
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9
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Campbell MJ, McCune E, Rothschild H, Bolen J, VandenBerg S, Chien J, Wong J, Esserman L. Abstract P2-09-02: Modulation of the immune microenvironment in high risk DCIS by intralesional injection of anti-PD-1 (pembrolizumab). Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p2-09-02] [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: 11/16/2022]
Abstract
Abstract
Background. Ductal carcinoma in situ (DCIS) is a risk factor for the subsequent development of invasive breast cancer. Features of DCIS that are associated with a high risk of a subsequent event include large size (> 5 cm), high grade, comedo necrosis, palpable mass, hormone receptor negativity, and HER2 positivity. We have previously shown that immune infiltrates are positively associated with these high-risk features, suggesting that manipulating the immune microenvironment in high-risk DCIS, for example via checkpoint blockade, could potentially alter disease progression.
Methods. In this phase 1 pilot study we investigated changes in the immune microenvironment of high risk DCIS after intralesional injection of anti-PD-1 (pembrolizumab). Study participants received 2 intralesional injections of pembrolizumab, 3 weeks apart, with surgery approximately 3 weeks after the 2nd dose. The study started with a dose of 2 mg/injection (1/100 of the standard 200 mg iv dose), then escalated to 4 mg and 8 mg, with 3 patients at each dose. Tissue samples from pre-treatment biopsies and post-treatment surgical resections were stained with two 6-plex immune panels using Opal immunofluorescence reagents (Perkin Elmer) on a fully automated Ventana Discovery platform, imaged with a Vectra 3 system and analyzed with inForm software (Perkin Elmer). An algorithm for tumor/stroma segmentation developed in inForm was used to randomly select 10 high power fields (hpfs) for imaging. Cell phenotype maps were generated for each of these hpfs for each sample. Cell densities were determined per area of stroma, DCIS, or total tissue and averaged across all hpfs for a given case. Spatial analyses were performed to quantitate co-localization of immune cells with DCIS cells.
Results. The intralesional injections were easily administered and well tolerated. No systemic toxicities were observed at any dose. MRI imaging demonstrated no change in the size of lesions after treatment. Multiplex immunofluorescence analyses demonstrated heterogeneous responses ranging from dramatic increases in T cells, in particular CD8+ T cells, in cases which had a T cell infiltrate prior to therapy, to no post-therapy T cell infiltrate in cases with a pre-therapy immune desert. We also observed increases in B cells and macrophages and a decrease in the ratio of FoxP3+ T cells to CD8+ T cells, the latter mainly due to a significant increase in CD8+ cells, as opposed to a decrease in FoxP3+ cells. Spatial analyses indicated that in some cases, despite a marked increase in T cells post therapy, these cells did not co-localize with DCIS cells, indicating a state of immune exclusion.
Conclusions. We have demonstrated the safety and feasibility of intralesional injection of an immune checkpoint inhibitor (pembrolizumab) in high risk DCIS. In some patients we observed a dramatic change in the immune microenvironment, with an increase in T cells, B cells, and macrophages, and a decrease in the FoxP3:CD8 ratio, even at a dose that is 1/100 of the standard intravenous clinical dose. An expansion study is underway in which patients will receive 4 injections of pembrolizumab at 3 week intervals prior to going to surgery to determine if more injections/time will increase response rate.
Citation Format: Campbell MJ, McCune E, Rothschild H, Bolen J, VandenBerg S, Chien J, Wong J, Esserman L. Modulation of the immune microenvironment in high risk DCIS by intralesional injection of anti-PD-1 (pembrolizumab) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-09-02.
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Affiliation(s)
| | - E McCune
- University of California, San Francisco, CA
| | | | - J Bolen
- University of California, San Francisco, CA
| | | | - J Chien
- University of California, San Francisco, CA
| | - J Wong
- University of California, San Francisco, CA
| | - L Esserman
- University of California, San Francisco, CA
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Campbell MJ, Tandon V, Senman B, Li J, Esserman L. Abstract P4-06-02: Chemoimmunotherapy with cyclophosphamide plus a toll-like receptor 9 (TLR9) agonist eradicates triple negative breast cancer in a murine model. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p4-06-02] [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: 11/16/2022]
Abstract
Abstract
Background. Toll-like receptors (TLR) recognize conserved molecular patterns expressed by microbes and together with other molecular sensors serve as a first line of defense, inducing soluble and cellular mediators of innate immunity and initiating key steps of an adaptive immune response. The use of TLR agonists for therapeutic purposes relies on the ability of these compounds to induce, at least partially, some of the immune events that occur during natural infections. For example, synthetic CpG-containing oligodeoxynucleotides (ODN) act as TLR9 agonists, mimicking stimulation of the immune system by bacterial or viral DNA. CpG ODNs are being developed for cancer immunotherapy based on their capacity to stimulate innate and adaptive anti-tumor responses. In this study, we examined the efficacy of intratumorally administered CpG-ODN 1826 alone or in combination with immunomodulatory antibodies (anti-PD-1, anti-OX40, anti-CTLA4) or chemotherapy (cyclophosphamide, paclitaxel) in the syngeneic mouse 4T1 breast tumor model.
Methods. Tumors were implanted orthotopically in the mammary fat pads on the left and right flanks while only one tumor was injected with CpG-ODN 1826. Therapy began 12-14 days post tumor injection when tumors were 8-10 mm in diameter. CpG-ODN 1826 (100 ug) was administered intratumorally, while immunomodulatory antibodies (anti-PD-1 [200 ug], anti-CTLA4 [100 ug], anti-OX40 [400 ug]) and chemotherapies (cyclophosphamide [150 mg/kg], paclitaxel [10 mg/kg]) were administered intraperitoneally. Tumor volume was monitored on both flanks to assess direct and abscopal/systemic anti-tumor activity. Tumor tissue obtained during the treatment regimen was used to evaluate therapy-induced changes in the immune microenvironment.
Results. CpG-ODN 1826, administered intratumorally over 5 consecutive days induced complete regressions in ˜50% of the treated tumors, but only delayed growth in the distant lesions. The immunomodulatory antibodies had little effect on their own and did not add to the therapeutic efficacy of CpG-ODN 1826. The best therapeutic efficacy was obtained with a combination of weekly cyclophosphamide + CpG-ODN 1826 resulting in complete regression of both the CpG injected tumors and the contralateral tumors in 100% of the mice.
Conclusions. These data support the clinical investigation of the combination of a TLR9 agonist (CpG-ODN) with cyclophosphamide in women with breast cancer.
Citation Format: Campbell MJ, Tandon V, Senman B, Li J, Esserman L. Chemoimmunotherapy with cyclophosphamide plus a toll-like receptor 9 (TLR9) agonist eradicates triple negative breast cancer in a murine model [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-02.
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Affiliation(s)
| | - V Tandon
- University of California, San Francisco, CA
| | - B Senman
- University of California, San Francisco, CA
| | - J Li
- University of California, San Francisco, CA
| | - L Esserman
- University of California, San Francisco, CA
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Reynolds CJ, MacNeill SJ, Williams J, Hodges NG, Campbell MJ, Newman Taylor AJ, Cullinan P. Chronic obstructive pulmonary disease in Welsh slate miners. Occup Med (Lond) 2017; 67:20-25. [PMID: 27816911 DOI: 10.1093/occmed/kqw147] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Exposure to respirable crystalline silica (RCS) causes emphysema, airflow limitation and chronic obstructive pulmonary disease (COPD). Slate miners are exposed to slate dust containing RCS but their COPD risk has not previously been studied. AIMS To study the cumulative effect of mining on lung function and risk of COPD in a cohort of Welsh slate miners and whether these were independent of smoking and pneumoconiosis. METHODS The study was based on a secondary analysis of Medical Research Council (MRC) survey data. COPD was defined as forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) ratio <0.7. We created multivariable models to assess the association between mining and lung function after adjusting for age and smoking status. We used linear regression models for FEV1 and FVC and logistic regression for COPD. RESULTS In the original MRC study, 1255 men participated (726 slate miners, 529 unexposed non-miners). COPD was significantly more common in miners (n = 213, 33%) than non-miners (n = 120, 26%), P < 0.05. There was no statistically significant difference in risk of COPD between miners and non-miners when analysis was limited to non-smokers or those without radiographic evidence of pneumoconiosis. After adjustment for smoking, slate mining was associated with a reduction in %predicted FEV1 [β coefficient = -3.97, 95% confidence interval (CI) -6.65, -1.29] and FVC (β coefficient = -2.32, 95% CI -4.31, -0.33) and increased risk of COPD (odds ratio: 1.38, 95% CI 1.06, 1.81). CONCLUSIONS Slate mining may reduce lung function and increase the incidence of COPD independently of smoking and pneumoconiosis.
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Affiliation(s)
- C J Reynolds
- National Heart and Lung Institute, Imperial College London, London SW3 6LR, UK,
| | - S J MacNeill
- School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
| | - J Williams
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - N G Hodges
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - M J Campbell
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - A J Newman Taylor
- National Heart and Lung Institute, Imperial College London, London SW3 6LR, UK
| | - P Cullinan
- National Heart and Lung Institute, Imperial College London, London SW3 6LR, UK
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Abstract
Neuromuscular function has been studied in multiple sclerosis patients with differing levels of disability. Force during maximal voluntary ankle dorsiflexion and surface EMG in tibialis anterior for weakest and strongest legs in 31 patients was compared with 16 control subjects. In the most mildly affected patients strength of dorsiflexion for the strongest leg was not significantly different from that of controls, but integrated mean EMG and median frequency of the power spectrum were significantly lower. In all other patient groups, all parameters measured were different from control values. Results indicate an important change in neuromuscular parameters which precedes loss of the ability to recruit normal force levels. Such changes may imply that the muscles of multiple sclerosis patients are affected even before there is significant evidence of neural motor dysfunction.
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Affiliation(s)
- R. Jones
- Biophysics Group, Bristol Oncology Centre
| | - DP Rees
- Department of Physiotherapy Education, Avon and Gloucestershire College of Health
| | - MJ Campbell
- Department of Neurology, United Bristol Healthcare Trust, Bristol Royal Infirmary, Bristol
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Barker D, McElduff P, D'Este C, Campbell MJ. Stepped wedge cluster randomised trials: a review of the statistical methodology used and available. BMC Med Res Methodol 2016; 16:69. [PMID: 27267471 PMCID: PMC4895892 DOI: 10.1186/s12874-016-0176-5] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [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: 01/21/2016] [Accepted: 05/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials. METHODS Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design. RESULTS This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used. CONCLUSIONS Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.
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Affiliation(s)
- D Barker
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - P McElduff
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - C D'Este
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, 0200, Australia
| | - M J Campbell
- Medical Statistics Group, ScHARR, University of Sheffield, Sheffield, UK
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Amara D, Wolf D, van 't Veer L, Esserman LJ, Campbell MJ, Yau C. Abstract P5-08-12: Co-expression modules identified from published immune signatures reveals five distinct immune subtypes in breast cancer. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p5-08-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction
Immune modulating therapies offer an attractive novel approach in the treatment of breast cancer. There is a growing body of literature demonstrating that immune-related expression signatures predict breast cancer prognosis and chemo- and/or targeted therapy responsiveness. However, it is unclear how these signatures relate to one another. Here we evaluated 58 immune signatures in breast cancer and generated co-expression modules to classify patients into immune subtypes.
Methods
We evaluated 58 published expression signatures related to immune function in 5 breast cancer gene expression datasets (TCGA (n=817), METABRIC (n=1992), EMC344 (n=344), pooled triple negative: GSE31519 (n=579), pooled neoadjuvant chemotherapy treated: GSE25066 (n=508)). For each dataset, consensus clustering was used to subset the signatures based on their co-expression pattern. Signatures in the same consensus cluster across all 5 datasets were used to define immune modules. Module scores were computed as the average across their constituent signatures. Patients were classified into immune subtypes based on their module scores using consensus clustering. Overall survival (OS) differences between immune subtypes were assessed using Cox proportional hazard modeling in basal breast cancers from the METABRIC dataset (n=329).
Results
Consensus clustering of the 58 expression signatures consistently yields four distinct co-expression modules across the five datasets. These modules appear to represent distinct immune components and signals, with constituent signatures relating to: 1) T-cells and/or B-cells (T/B-cell), 2) interferon (IFN), 3) transforming growth factor beta (TGFB), 4) core serum response, dendritic cells and/or macrophages (CSR). Of note, the T/B-cell module contains 20 of the 58 signatures evaluated; and the CSR module is highly correlated to proliferation (r=0.81). Subtyping of patients based on these co-expression modules consistently yields subsets that fall into five major immune subtypes. The expression pattern of the four modules within each immune subtype is summarized below:
T/B-cellIFNTGFBCSRT/B-cell/IFN HighHighHighIntermediateIntermediateIFN/CSR HighLowHighLowHighImmune LowLowLowLowLowCSR HighLowLowLowHighTGFB HighLowLowHighLowImmune Co-expression Modules (columns); Immune Subtypes (rows)
These immune subtypes are associated with differences in overall survival in the METABRIC basal breast cancer cases, where the CSR High subtype has the worst outcome (10-year OS: 23%). In comparison, the subsets corresponding to the T/B-cell/IFN High subtype have better outcomes (Hazard ratio: 0.43, p = 0.018). In contrast, no significant outcome differences were observed between the poor outcome CSR-High subtype and the remaining three immune subtypes (p>0.05).
Conclusion
Our exploratory study identified four distinct immune co-expression modules (T/B-cell, IFN, TGFB, or CSR) from a collection of published immune signatures. Using these modules, we identified 5 immune subtypes with prognostic significance in basal breast cancers. We propose to test representative signatures from the 4 modules and the combined immune subtypes as predictive biomarkers of response to immunotherapies.
Citation Format: Amara D, Wolf D, van 't Veer L, Esserman LJ, Campbell MJ, Yau C. Co-expression modules identified from published immune signatures reveals five distinct immune subtypes in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-12.
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Affiliation(s)
- D Amara
- UCSF Comprehensive Cancer Center, San Francisco, CA
| | - D Wolf
- UCSF Comprehensive Cancer Center, San Francisco, CA
| | | | - LJ Esserman
- UCSF Comprehensive Cancer Center, San Francisco, CA
| | - MJ Campbell
- UCSF Comprehensive Cancer Center, San Francisco, CA
| | - C Yau
- UCSF Comprehensive Cancer Center, San Francisco, CA
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Hoo ZH, Curley R, Carolan C, Hinchliffe C, Hutchings M, Campbell MJ, Wildman MJ. P274 Moving from rescue to prevention: real world evidence of reduction in IV antibiotic requirement following improvement in adherence to maintenance nebulised treatment in an adult cystic fibrosis centre: Abstract P274 Table 1. Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.410] [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: 11/03/2022]
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Dworschak M, Campbell MJ. About the benefits and limitations of pilot studies. Minerva Anestesiol 2015; 81:711-712. [PMID: 25479475] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- M Dworschak
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, General Hospital Vienna, Medical University of Vienna, Vienna, Austria -
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Elliott J, Rankin D, Jacques RM, Lawton J, Emery CJ, Campbell MJ, Dixon S, Heller SR. A cluster randomized controlled non-inferiority trial of 5-day Dose Adjustment for Normal Eating (DAFNE) training delivered over 1 week versus 5-day DAFNE training delivered over 5 weeks: the DAFNE 5 × 1-day trial. Diabet Med 2015; 32:391-8. [PMID: 25363466 DOI: 10.1111/dme.12621] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/04/2014] [Accepted: 10/28/2014] [Indexed: 12/24/2022]
Abstract
AIMS To compare, in a randomized controlled non-inferiority trial, the outcomes of the traditional format for Dose Adjustment for Normal Eating structured education courses; that is, one delivered over 5 consecutive days (1-week course) with a variant of this format delivered 1 day a week for 5 consecutive weeks (5-week course). METHODS Adults with Type 1 diabetes, from seven UK Dose Adjustment For Normal Eating training centres, were individually randomized, stratified by centre, to receive either a 1-week or 5-week course. A qualitative study was embedded within the trial to explore patients' experiences. RESULTS In total, 213 patients were randomized and 160 completed the study procedures. In the per-protocol analysis, the difference in HbA1c levels (95% CI) between the arms at 6 months was 0.4 mmol/mol (-2.4, 3.1) or 0.03% (-0.22, 0.28) and -0.9 mmol/mol (-3.9, 2.2) or -0.08% (-0.36, 0.20) at 12 months. All confidence limits were within the non-inferiority margin of ± 5.5 mmol/mol (0.5%) for HbA1c %. For those patients with a baseline HbA1c of ≥ 58 mmol/mol (≥ 7.5%) the mean change (95% CI) in HbA1c was -2.2 mmol/mol (-4.0, -0.4) or -0.20% (-0.37, -0.04) at 6 months (P = 0.016), and -2.0 mmol/mol (-4.1, 0.04) or -0.18% (-0.37 to 0.004) at 12 months (P = 0.055). Episodes of severe hypoglycaemia were decreased by 82% [relative risk 0.18 (95% CI 0.03-0.936); P = 0.042], psychosocial outcomes improved significantly, and the difference between arms was not significant. Qualitative interviews showed that patients overwhelmingly favoured the format of course that they attended. CONCLUSIONS In summary, 5-week and 1-week Dose Adjustment for Normal Eating courses are equivalent in terms of biomedical and psychosocial outcomes, and we were persuaded that both course formats should be made available in routine care.
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Affiliation(s)
- J Elliott
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Human Metabolism, University of Sheffield, Sheffield, UK
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18
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Latimer NR, Abrams KR, Lambert PC, Crowther MJ, Wailoo AJ, Morden JP, Akehurst RL, Campbell MJ. Adjusting for treatment switching in randomised controlled trials – A simulation study and a simplified two-stage method. Stat Methods Med Res 2014; 26:724-751. [DOI: 10.1177/0962280214557578] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Estimates of the overall survival benefit of new cancer treatments are often confounded by treatment switching in randomised controlled trials (RCTs) – whereby patients randomised to the control group are permitted to switch onto the experimental treatment upon disease progression. In health technology assessment, estimates of the unconfounded overall survival benefit associated with the new treatment are needed. Several switching adjustment methods have been advocated in the literature, some of which have been used in health technology assessment. However, it is unclear which methods are likely to produce least bias in realistic RCT-based scenarios. We simulated RCTs in which switching, associated with patient prognosis, was permitted. Treatment effect size and time dependency, switching proportions and disease severity were varied across scenarios. We assessed the performance of alternative adjustment methods based upon bias, coverage and mean squared error, related to the estimation of true restricted mean survival in the absence of switching in the control group. We found that when the treatment effect was not time-dependent, rank preserving structural failure time models (RPSFTM) and iterative parameter estimation methods produced low levels of bias. However, in the presence of a time-dependent treatment effect, these methods produced higher levels of bias, similar to those produced by an inverse probability of censoring weights method. The inverse probability of censoring weights and structural nested models produced high levels of bias when switching proportions exceeded 85%. A simplified two-stage Weibull method produced low bias across all scenarios and provided the treatment switching mechanism is suitable, represents an appropriate adjustment method.
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Affiliation(s)
- Nicholas R Latimer
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - KR Abrams
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - PC Lambert
- Department of Health Sciences, University of Leicester, Leicester, UK
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - MJ Crowther
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - AJ Wailoo
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - JP Morden
- Clinical Trials and Statistics Unit (ICR-CTSU), Division of Clinical Studies, The Institute of Cancer Research, London, UK
| | - RL Akehurst
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - MJ Campbell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Basarir H, Pollard D, Brennan A, Elliott J, Heller S, Campbell MJ. The Potential Value of Ongoing Support In Type-1 Diabetes Mellitus With Dafneplus: Exploratory Pre-Trial Cost-Effectiveness Analysis On Proposed Trial End-Point Target For 12-Month Hba1c Improvement. Value Health 2014; 17:A350. [PMID: 27200678 DOI: 10.1016/j.jval.2014.08.725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- H Basarir
- University of Sheffield, Sheffield, UK
| | - D Pollard
- University of Sheffield, Sheffield, UK
| | - A Brennan
- University of Sheffield, Sheffield, UK
| | - J Elliott
- University of Sheffield, Sheffield, UK
| | - S Heller
- University of Sheffield, Sheffield, UK
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20
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Elliott J, Jacques RM, Kruger J, Campbell MJ, Amiel SA, Mansell P, Speight J, Brennan A, Heller SR. Substantial reductions in the number of diabetic ketoacidosis and severe hypoglycaemia episodes requiring emergency treatment lead to reduced costs after structured education in adults with Type 1 diabetes. Diabet Med 2014; 31:847-53. [PMID: 24654672 PMCID: PMC4264891 DOI: 10.1111/dme.12441] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 11/25/2013] [Accepted: 03/17/2014] [Indexed: 12/29/2022]
Abstract
AIMS To determine the impact of structured education promoting flexible intensive insulin therapy on rates of diabetic ketoacidosis, and the costs associated with emergency treatment for severe hypoglycaemia and ketoacidosis in adults with Type 1 diabetes. METHODS Using the Dose Adjustment For Normal Eating research database we compared the rates of ketoacidosis and severe hypoglycaemia during the 12 months preceding Dose Adjustment For Normal Eating training with the rates during the 12-month follow-up after this training. Emergency treatment costs were calculated for associated paramedic assistance, Accident and Emergency department attendance and hospital admissions. RESULTS Complete baseline and 1-year data were available for 939/1651 participants (57%). The risk of ketoacidosis in the 12 months after Dose Adjustment For Normal Eating training, compared with that before training, was 0.39 (95% CI: 0.23 to 0.65, P < 0.001), reduced from 0.07 to 0.03 episodes/patient/year. For every 1 mmol/mol unit increase in HbA1c concentration, the risk of a ketoacidosis episode increased by 6% (95% CI: 5 to 7%; 88% for a 1% increase), and for each 5-year increase in diabetes duration, the relative risk reduced by 20% (95% CI: 19 to 22%). The number of emergency treatments decreased for ketoacidosis (P < 0.001), and also for severe hypoglycaemia, including paramedic assistance (P < 0.001), Accident and Emergency department attendance (P = 0.029) and hospital admission (P = 0.001). In the study cohort, the combined cost of emergency treatment for ketoacidosis and severe hypoglycaemia fell by 64%, from £119,470 to £42,948. CONCLUSIONS Structured training in flexible intensive insulin therapy is associated with a 61% reduction in the risk of ketoacidosis and with 64% lower emergency treatment costs for ketoacidosis and severe hypoglycaemia.
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Affiliation(s)
- J Elliott
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Human Metabolism, The University of Sheffield, Sheffield, UK
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Abstract
OBJECTIVE To determine the impact of the GP-led walk-in centre (WIC) in Sheffield (England) on the demand for emergency department (ED) care. METHODS A survey of patients visiting the Sheffield GP WIC was conducted over 3 weeks during September and October 2011. A short, postvisit questionnaire was also sent to those who agreed to determine if the patient had used another NHS service for the same problem. Routine data were obtained from the adult and children's EDs and minor injuries unit in Sheffield, 1 year before and 1 year after the opening of the GP WIC. A linear model of the number of minor daytime attendances (GP type) per month was used to estimate the impact of opening the GP WIC, after controlling for seasonal variation and a linear time trend. RESULTS A total of 529 patients responded to the survey (response rate 51%). Based on their self-reported intentions, 64 of these patients (53 adults and 11 children) were diverted from going to ED in the 3-week survey period as a result of the establishment of the GP WIC. From this we would have expected around a 26% monthly reduction in GP-type attendances at adult ED, and 7% reduction at children's ED. However, routine data only showed an 8% (95% CI 1% to 16%) reduction at the adult ED. Reductions in GP-type attendances at the children's ED and the minor injury unit at the time of the opening of the GP WIC were also found, but were not statistically significant. The estimated impact on children's ED was a 14% reduction (95% CI -38% to 8%), and for minor injuries unit (MIU) a 4% reduction (95% CI -18 to 9%). CONCLUSIONS There was a statistically significant reduction in GP-type daytime attendances at the adult ED after the opening of the GP WIC. Since this reduction was not mirrored in changes in night-time attendances (when the GP WIC was closed), and our survey responses suggested some people were diverted from going to the ED, it is possible that the opening of the GP WIC caused this reduction.
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Affiliation(s)
- M Arain
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - M J Campbell
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - J P Nicholl
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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Campbell MJ, Senman B, Esserman LJ. Abstract P5-01-06: Remodeling the tumor immune microenvironment via intratumoral administration of immunomodulatory agents. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-p5-01-06] [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: 11/16/2022]
Abstract
Abstract
Background: Immune dysregulation has been implicated in the poor outcomes associated with high grade and/or triple negative (Tneg) breast cancers. This suggests that a multi-modal approach to stimulating the immune system could be an effective therapeutic strategy for Tneg breast cancer. However, many immunotherapeutic agents demonstrate significant toxicities when administered systemically at high doses. Therefore, we investigated the therapeutic efficacy of local, intratumoral administration of immunomodulators in a mouse model of Tneg breast cancer.
Methods: 4T1, an aggressive, Tneg mammary carcinoma, was implanted orthotopically into syngeneic BALB/c mice. Treatment was initiated when tumors were 0.5-1.0 cm in the largest dimension. We examined various combinations of Toll-like receptor agonists (CpG oligonucleotide [TLR9] and imiquimod [TLR7]) with immunomodulatory antibodies (anti-CD40, anti-CTLA-4, anti-OX40). These agents were administered intratumorally (i.t.), either in PBS or formulated in an in situ depot forming drug delivery system. Growth of the injected tumors was monitored over time. In some experiments, tumors and spleens were harvested 3-10 days post therapy and analyzed for the presence of CD4+ T cells, CD8+ T cells, immunoregulatory T cells (Treg), and myeloid derived suppressor cells (MDSC). To test whether local immunotherapy generates a systemic antitumor immune response, 4T1 tumors were implanted at 2 sites on opposite sides of the mice, with one (left) used as the site of in situ immunomodulation (i.t. injections) and the other (right) observed to assess the systemic antitumor immune response.
Results: Intratumoral administration of various combinations of immunomodulators resulted in complete regression of the injected tumor. These regressions were associated with a reduction in the number of MDSCs in the tumor as well as activation of both CD4+ and CD8+ T cells. Furthermore, local immunotherapy generated a systemic antitumor immune response that inhibited tumors growing at a distant site.
Conclusions: Our findings demonstrate that remodeling the tumor immune microenvironment via intratumoral administration of immunomodulatory agents elicits antitumor immunity that eradicates tumor cells locally as well as systemically at distant sites. The prospect of delivering immunotherapeutics only where it matters most, namely within the tumor microenvironment, is extremely attractive as this would likely be substantially less toxic and more specific than many of the current cancer treatments. Ongoing studies include identifying companion diagnostics that can indicate which patients would benefit most from such an immunotherapeutic approach.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-01-06.
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Affiliation(s)
| | - B Senman
- University of California, San Francisco, CA
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Affiliation(s)
- J Nicholl
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield S1 4DA, UK
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Adisa CA, Eleweke N, Alfred AA, Campbell MJ, Sharma R, Nseyo O, Tandon V, Mukhtar R, Greninger A, Risi JD, Esserman LJ. Biology of breast cancer in Nigerian women: a pilot study. Ann Afr Med 2012; 11:169-75. [PMID: 22684136 DOI: 10.4103/1596-3519.96880] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Compared to the developed world, there are relatively few studies that describe the tumor biology of breast cancer in African women. While little is known about the tumor biology, clinical and epidemiologic studies suggest that breast cancer in African women are characterized by presentation at late stage and poor clinical outcomes. Analysis of the biological features of breast cancers in Nigerian women was designed to bring additional insight to better understand the spectrum of disease, the phenotypes that present, and the types of interventions that might improve outcomes. MATERIALS AND METHODS We performed histological analyses for hormone receptors (estrogen and progesterone receptors), HER2, and tumor infiltrating macrophages (TAM) on 17 breast cancers, obtained from Abia State University Teaching Hospital (Aba, Nigeria), between November 2008 and October 2009. On a subset of these cases, we investigated the potential role of a virus in the etiology of these aggressive cancers. RESULTS The majority of cases in this cohort were characterized as high grade (100% were grade III), triple-negative (65%), and occur in young women (mean age 47 years). We observed high infiltration of TAMs in these tumors, but no evidence of a viral etiology. CONCLUSION Our findings indicate that breast cancers in Nigerian women have a highly aggressive phenotype (high grade, hormone receptor negative), which is similar to other studies from Africa and other developing nations, as well as from African American women, but is significantly different from Caucasian women in the developed world. The presence of high numbers of TAMs in these tumors raises the possibility of targeting the immune microenvironment for therapeutic interventions.
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Affiliation(s)
- C A Adisa
- Department of Surgery, Abia State University Teaching Hospital, Aba, Nigeria
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Mukhtar R, Wolf D, Tandon V, Zhu J, Lenburg M, van't VL, Campbell MJ. P4-09-19: PCNA+ Tumor Associated Macrophages Are Associated with M1 and M2 Gene Expression, and Confer Poor Prognosis in the Absence of Anti-Tumor Immune Environment. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-p4-09-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
Tumor associated macrophages (TAMs) promote breast tumor progression through the production of angiogenic factors, stromal breakdown factors, and the suppression of adaptive immunity. TAMs are recruited from the circulation to the tumor site, and can undergo a spectrum of phenotypic changes, with two contrasting activation states described in the literature: the M1 anti-tumoral and M2 pro-tumoral phenotypes. We previously identified a population of PCNA+ TAMs associated with high grade, hormone receptor (HR) negative tumors with poor outcomes. We hypothesized that high PCNA+ TAMs would be associated with expression of M2 related genes.
Methods
We used immunohistochemistry to measure PCNA+ TAM levels (double positive for PCNA and CD68) in 135 invasive breast cancer cases from the I-SPY 1 Trial, a prospective neoadjuvant trial with serial core biopsies and gene array data. We developed gene-sets representing M1 related, M2 related, and anti-tumoral immune response (represented by cytotoxic T cells and MHC Class II) genes based on literature review. We compared PCNA+ TAM levels, expression of these gene-sets, and outcomes.
Results
Higher than mean PCNA+ TAM counts were associated with increasing grade (p < 0.001), HR negativity (p < 0.001), and decreased recurrence free survival (RFS, p = 0.05). Among subjects who had a pathologic complete response (pCR), there was no difference in RFS between those with high versus low PCNA+ TAMs. Among subjects without pCR, those with high PCNA+ TAMs had significantly worse RFS than those with low PCNA+ TAMs (p = 0.0028). In the 95 subjects with both PCNA+ TAM results and gene expression arrays available, high PCNA+ TAM levels were associated with more M1 than M2 related genes. The gene-set representing anti-tumoral immune environment was not by itself associated with RFS. However, those subjects with both high PCNA+ TAMs and the absence of anti-tumoral immune response gene expression had significantly worse RFS than those with high PCNA+ TAMs but the presence of anti-tumoral immune related genes (p = 0.01).
Conclusions
High PCNA+ TAMs had different effects on outcomes depending on tumoral immune environment. Instead of being purely M2 macrophages, PCNA+ TAMs likely represent a heterogeneous mixture of TAMs with different polarization states. Additional markers are needed to distinguish anti-tumoral from pro-tumoral PCNA+ TAMs.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-09-19.
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Affiliation(s)
- R Mukhtar
- 1I-SPY Trial Investigators, Esserman LJ. UCSF; Boston University
| | - D Wolf
- 1I-SPY Trial Investigators, Esserman LJ. UCSF; Boston University
| | - V Tandon
- 1I-SPY Trial Investigators, Esserman LJ. UCSF; Boston University
| | - J Zhu
- 1I-SPY Trial Investigators, Esserman LJ. UCSF; Boston University
| | - M Lenburg
- 1I-SPY Trial Investigators, Esserman LJ. UCSF; Boston University
| | - Veer L van't
- 1I-SPY Trial Investigators, Esserman LJ. UCSF; Boston University
| | - MJ Campbell
- 1I-SPY Trial Investigators, Esserman LJ. UCSF; Boston University
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Julious SA, Campbell MJ, Bianchi SM, Murray-Thomas T. Seasonality of medical contacts in school-aged children with asthma: association with school holidays. Public Health 2011; 125:769-76. [PMID: 22036686 DOI: 10.1016/j.puhe.2011.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 07/04/2011] [Accepted: 08/22/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To assess the seasonality of medical contacts in children with asthma, to compare England with Scotland, and to assess the impact of medication compliance on the frequency of medical contacts. STUDY DESIGN A retrospective study taken from the General Practice Research Database of daily medical contacts from 1999 to 2005 in a population of school-aged (5-16 years) children with a diagnosis of asthma, and age- and gender-matched controls. PRIMARY OUTCOME MEASURE All unscheduled medical contacts. Prescription frequency for inhaled corticosteroids over the same period was also assessed. RESULTS Data from 76,924 children were analyzed. There was an increase in unscheduled medical contacts for all children on return to school in September. Unscheduled medical contacts occurred almost twice as frequently in children with asthma compared with non-asthmatic children. The frequency of medical contacts in children with asthma could be predicted from the frequency of medical contacts in non-asthmatic children. In the 3 months from September to December, unscheduled medical contacts were disproportionately greater than would be predicted for children with asthma relative to non-asthmatic children in both England and Scotland. The rise in medical contacts in Scotland preceded that in England by approximately 14 days, reflecting the earlier date for returning to school. The number of prescriptions for inhaled corticosteroids decreased in August. A higher incidence of unscheduled medical contacts was noted during September in those not receiving a prescription in August. CONCLUSIONS Returning to school after the summer break is associated with a sharp increase in unscheduled medical contacts in school-aged children, particularly in those with asthma. This follows a decrease in the number of prescriptions for inhaled corticosteroids. It is suggested that at least part of the excess numbers of unscheduled contacts in children with asthma is because they do not maintain their inhaled corticosteroids over the summer holidays.
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Affiliation(s)
- S A Julious
- Medical Statistics Group, ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
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Abstract
BACKGROUND Scabies is a contagious parasitic infestation which causes an allergic reaction to just a few mites. OBJECTIVES To examine the epidemiology of scabies consultations in the U.K. by age, sex, region of the country and time. METHODS Data were obtained from the THIN (The Health Information Network) database provided by EPIC U.K. in which each consultation episode is coded according to a 'READ' code. Data were available for 1997-2005 inclusive (9 years) for approximately 8·5% of the U.K. population from 12 regions of the U.K. We used harmonic analysis to model the data over time and derived cycle amplitudes and phases for each region in the U.K. RESULTS There was a significantly greater infestation rate among females with a relative risk of 1·24 (P < 0·001) relative to males. The age group 10-19 years had the highest infestation rates (with rates of 4·55 per 1000 and 5·92 per 1000 for males and females, respectively). The middle age groups had the smallest infestation rates. A cycle with length of between 15 and 17 years was derived, and the phase times of the cycles for each region suggested a progression of the disease originating from the North East, spreading to Northern parts of the U.K. and then to the Midlands and the South. CONCLUSIONS The study confirms earlier studies with regard to the age/sex distribution of scabies. We suggest a contagious pattern of spread of scabies infestation in the U.K. with an epidemic cycle length of 15-17 years.
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Affiliation(s)
- S Lassa
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Campbell MJ, Zhu J, Yau C, Muhktar R, Nseyo O, Benz CC, Esserman LJ. Abstract P5-04-01: Expression of Genes Associated with the Innate Immune System and Response to Neoadjuvant Chemotherapy in Breast Cancer. Cancer Res 2010. [DOI: 10.1158/0008-5472.sabcs10-p5-04-01] [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: 11/16/2022]
Abstract
Abstract
Background: The efficacy of cancer chemotherapy is generally assessed by the ability to directly kill or inhibit the growth of cancer cells. However, there is evidence suggesting that anticancer immune responses also contribute to the efficacy of conventional chemotherapy. Recent studies have shown that chemotherapeutic agents (anthracyclines in particular) can elicit innate immune responses via the release of proteins from dying tumor cells that interact with Toll-like receptors (TLR) on macrophages (mΦ) and dendritic cells (DC). The subsequent induction of cytotoxic T cell responses leads to the elimination of residual cancer cells not killed by the chemotherapy. To test this idea of chemotherapy-induced immunogenic cell death in breast cancer, we examined gene expression data for women with breast cancer treated neoadjuvantly, starting with adriamycin, on the I-SPY TRIAL (2003-2006), to see if genes that predict this type of immune response would also predict complete pathologic response (pCR) Methods: A panel of 47 genes were selected, including those expressed by the cancer cells as well as infiltrating immune cells: TLR/mΦ/DC activating proteins, TLR signaling genes, chemokines & chemokine receptors, cytokines & cytokine receptors, and mO, DC, & T cells markers. This gene set was then evaluated using expression array data from the I-SPY TRIAL, available on both Affymetrix (n=) and Agilent (n= 153) platforms. Initial analyses were performed using the UCSC Cancer Genomics Browser, a suite of web-based tools to integrate, visualize and analyze cancer genomics/expression data and clinical data. Differentially expressed genes were compared between patients who achieved a pathological complete response (pCR) following neoadjuvant chemotherapy vs. those who did not. A second independent data set available on the Cancer Genomics browser served as a validation set. These data, from MD Anderson, included 133 patients treated with neoadjuvant therapy (TFAC) with available Affymetrix array data.
Results: Of the 47 selected genes, 1 was not present on the Affymetrix array and 7 were absent from the Agilent array. Twelve of the 46 genes (26%) on the Affymetrix array and 20 of the 40 genes (50%) on the Agilent array were significantly differentially expressed comparing responders vs. non-responders. Overall, 25 of the 47 genes (53%) were differentially expressed on one or both arrays. Gene set enrichment and Paradigm pathway inference analyses confirmed that these genes are significantly enriched among responders. In the validation set, 20 of 46 genes (43%) were significantly differentially expressed.
Conclusion: We identified a panel of genes associated with immunogenic cell death and demonstrated their differential expression in patients who responded to neoadjuvant chemotherapy vs. non-responders. These results suggest a role for the host immune system in the response to chemotherapy. If the success of currently used chemotherapies depends on synergistic interactions with the immune system, then a better understanding of the mechanisms involved in chemotherapy-induced immunogenic cell death will provide a foundation for the design of novel chemo-immunotherapeutic strategies for breast cancer treatment.
Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-04-01.
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Affiliation(s)
- MJ Campbell
- University of California, San Francisco; University of California, Santa Cruz; Buck Institute for Age Research, Novato, CA
| | - J Zhu
- University of California, San Francisco; University of California, Santa Cruz; Buck Institute for Age Research, Novato, CA
| | - C Yau
- University of California, San Francisco; University of California, Santa Cruz; Buck Institute for Age Research, Novato, CA
| | - R Muhktar
- University of California, San Francisco; University of California, Santa Cruz; Buck Institute for Age Research, Novato, CA
| | - O Nseyo
- University of California, San Francisco; University of California, Santa Cruz; Buck Institute for Age Research, Novato, CA
| | - CC Benz
- University of California, San Francisco; University of California, Santa Cruz; Buck Institute for Age Research, Novato, CA
| | - LJ. Esserman
- University of California, San Francisco; University of California, Santa Cruz; Buck Institute for Age Research, Novato, CA
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Gillett M, Dallosso HM, Dixon S, Brennan A, Carey ME, Campbell MJ, Heller S, Khunti K, Skinner TC, Davies MJ. Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis. BMJ 2010; 341:c4093. [PMID: 20729270 PMCID: PMC2924963 DOI: 10.1136/bmj.c4093] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To assess the long term clinical and cost effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) intervention compared with usual care in people with newly diagnosed type 2 diabetes. DESIGN We undertook a cost-utility analysis that used data from a 12 month, multicentre, cluster randomised controlled trial and, using the Sheffield type 2 diabetes model, modelled long term outcomes in terms of use of therapies, incidence of complications, mortality, and associated effect on costs and health related quality of life. A further cost-utility analysis was also conducted using current "real world" costs of delivering the intervention estimated for a hypothetical primary care trust. SETTING Primary care trusts in the United Kingdom. PARTICIPANTS Patients with newly diagnosed type 2 diabetes. INTERVENTION A six hour structured group education programme delivered in the community by two professional healthcare educators. MAIN OUTCOME MEASURES Incremental costs and quality adjusted life years (QALYs) gained. RESULTS On the basis of the data in the trial, the estimated mean incremental lifetime cost per person receiving the DESMOND intervention is pound209 (95% confidence interval - pound704 to pound1137; euro251, -euro844 to euro1363; $326, -$1098 to $1773), the incremental gain in QALYs per person is 0.0392 (-0.0813 to 0.1786), and the mean incremental cost per QALY is pound5387. Using "real world" intervention costs, the lifetime incremental cost of the DESMOND intervention is pound82 (- pound831 to pound1010) and the mean incremental cost per QALY gained is pound2092. A probabilistic sensitivity analysis indicated that the likelihood that the DESMOND programme is cost effective at a threshold of pound20 000 per QALY is 66% using trial based intervention costs and 70% using "real world" costs. Results from a one way sensitivity analysis suggest that the DESMOND intervention is cost effective even under more modest assumptions that include the effects of the intervention being lost after one year. CONCLUSION Our results suggest that the DESMOND intervention is likely to be cost effective compared with usual care, especially with respect to the real world cost of the intervention to primary care trusts, with reductions in weight and smoking being the main benefits delivered.
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Affiliation(s)
- M Gillett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield.
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Campbell MJ. Statistical issues in Primary Care. Stat Methods Med Res 2010; 19:347-8. [PMID: 20696675 DOI: 10.1177/0962280209359881] [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: 11/15/2022]
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Hutchinson A, Coster JE, Cooper KL, McIntosh A, Walters SJ, Bath PA, Pearson M, Rantell K, Campbell MJ, Nicholl J, Irwin P. Assessing quality of care from hospital case notes: comparison of reliability of two methods. Qual Saf Health Care 2010; 19:e2. [PMID: 20511598 DOI: 10.1136/qshc.2007.023911] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To determine which of the two methods of case note review provide the most useful and reliable information for reviewing quality of care. DESIGN Retrospective, multiple reviews of 692 case notes were undertaken using both holistic (implicit) and criterion-based (explicit) review methods. Quality measures were evidence-based review criteria and a quality of care rating scale. SETTING Nine randomly selected acute hospitals in England. PARTICIPANTS Sixteen doctors, 11 specialist nurses and three clinically trained audit staff, and eight non-clinical audit staff. ANALYSIS METHODS: Intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs), completeness of criterion data capture and between-staff group comparison. RESULTS A total of 1473 holistic reviews and 1389 criterion-based reviews were undertaken. When the three same staff types reviewed the same record, holistic scale score inter-rater reliability was moderate within each group (ICC 0.46 to 0.52). Inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61 to 0.88). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement between the two methods. CONCLUSIONS Using a holistic approach to review case notes, same staff groups can achieve reasonable repeatability within their professional groups. When the same clinical record was reviewed twice by the doctors, and by the non-clinical audit staff, using both holistic and criterion-based methods, there are close similarities between the quality of care scores generated by the two methods. When using retrospective review of case notes to examine quality of care, a clear view is required of the purpose and the expected outputs of the project.
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Affiliation(s)
- A Hutchinson
- Section of Public Health, ScHARR, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
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Lancaster GA, Campbell MJ, Eldridge S, Farrin A, Marchant M, Muller S, Perera R, Peters TJ, Prevost AT, Rait G. Trials in primary care: statistical issues in the design, conduct and evaluation of complex interventions. Stat Methods Med Res 2010; 19:349-77. [PMID: 20442193 DOI: 10.1177/0962280209359883] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Trials carried out in primary care typically involve complex interventions that require considerable planning if they are to be implemented successfully. The role of the statistician in promoting both robust study design and appropriate statistical analysis is an important contribution to a multi-disciplinary primary care research group. Issues in the design of complex interventions have been addressed in the Medical Research Council's new guidance document and over the past 7 years by the Royal Statistical Society's Primary Health Care Study Group. With the aim of raising the profile of statistics and building research capability in this area, particularly with respect to methodological issues, the study group meetings have covered a wide range of topics that have been of interest to statisticians and non-statisticians alike. The aim of this article is to provide an overview of the statistical issues that have arisen over the years related to the design and evaluation of trials in primary care, to provide useful examples and references for further study and ultimately to promote good practice in the conduct of complex interventions carried out in primary care and other health care settings. Throughout we have given particular emphasis to statistical issues related to the design of cluster randomised trials.
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Affiliation(s)
- G A Lancaster
- Postgraduate Statistics Centre, Department of Maths and Statistics, Fylde College, Lancaster, UK.
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Hutchinson A, Coster JE, Cooper KL, McIntosh A, Walters SJ, Bath PA, Pearson M, Young TA, Rantell K, Campbell MJ, Ratcliffe J. Comparison of case note review methods for evaluating quality and safety in health care. Health Technol Assess 2010; 14:iii-iv, ix-x, 1-144. [DOI: 10.3310/hta14100] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [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)
- A Hutchinson
- Section of Public Health, ScHARR, University of Sheffield, UK
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Lee CP, Payne GS, Oregioni A, Ruddle R, Tan S, Raynaud FI, Eaton D, Campbell MJ, Cross K, Halbert G, Tracy M, McNamara J, Seddon B, Leach MO, Workman P, Judson I. A phase I study of the nitroimidazole hypoxia marker SR4554 using 19F magnetic resonance spectroscopy. Br J Cancer 2009; 101:1860-8. [PMID: 19935799 PMCID: PMC2788261 DOI: 10.1038/sj.bjc.6605425] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: SR4554 is a fluorine-containing 2-nitroimidazole, designed as a hypoxia marker detectable with 19F magnetic resonance spectroscopy (MRS). In an initial phase I study of SR4554, nausea/vomiting was found to be dose-limiting, and 1400 mg m−2 was established as MTD. Preliminary MRS studies demonstrated some evidence of 19F retention in tumour. In this study we investigated higher doses of SR4554 and intratumoral localisation of the 19F MRS signal. Methods: Patients had tumours ⩾3 cm in diameter and ⩽4 cm deep. Measurements were performed using 1H/19F surface coils and localised 19F MRS acquisition. SR4554 was administered at 1400 mg m−2, with subsequent increase to 2600 mg m−2 using prophylactic metoclopramide. Spectra were obtained immediately post infusion (MRS no. 1), at 16 h (MRS no. 2) and 20 h (MRS no. 3), based on the SR4554 half-life of 3.5 h determined from a previous study. 19Fluorine retention index (%) was defined as (MRS no. 2/MRS no. 1)*100. Results: A total of 26 patients enrolled at: 1400 (n=16), 1800 (n=1), 2200 (n=1) and 2600 mg m−2 (n=8). SR4554 was well tolerated and toxicities were all ⩽grade 1; mean plasma elimination half-life was 3.7±0.9 h. SR4554 signal was seen on both unlocalised and localised MRS no. 1 in all patients. Localised 19F signals were detected at MRS no. 2 in 5 out of 9 patients and 4 out of 5 patients at MRS no. 3. The mean retention index in tumour was 13.6 (range 0.6–43.7) compared with 4.1 (range 0.6–7.3) for plasma samples taken at the same times (P=0.001) suggesting 19F retention in tumour and, therefore, the presence of hypoxia. Conclusion: We have demonstrated the feasibility of using 19F MRS with SR4554 as a potential method of detecting hypoxia. Certain patients showed evidence of 19F retention in tumour, supporting further development of this technique for detection of tumour hypoxia.
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Affiliation(s)
- C P Lee
- Cancer Research UK Centre for Cancer Therapeutics, Cancer Research UK Clinical Magnetic Resonance Research Group and Section of Medicine, The Institute of Cancer Research and Drug Development Unit, The Royal Marsden Hospital, 15 Cotswold Road, Sutton, Surrey SM2 5NG, UK
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36
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Abstract
OBJECTIVE To investigate the importance of stratification by risk factors in computing the probability of a second death from sudden infant death syndrome (SIDS) in a family. DESIGN Simulation study. BACKGROUND The fact that a baby dies suddenly and unexpectedly means that there is a raised probability that the baby's family have risk factors associated with SIDS. Thus one cannot consider the risk of a subsequent death to be that of the general population. The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) identified three major social risk factors: smoking, age<27 and parity>1, and unemployed/unwaged as major risk factors. It gave estimates of risk for families with different numbers of these risk factors. We investigate whether it is reasonable to assume that, conditional on these risk factors, the risk of a second event is independent of the risk of the first and as a consequence one can square the risks to get the risk of two SIDS in a family. We have used CESDI data to estimate the probability of a second SID in a family under different plausible scenarios of the prevalence of the risk factors. We have applied the model to make predictions in the Care of Next Infant (CONI) study. RESULTS The model gave plausible predictions. The CONI study observed 18 second SIDS. Our model predicted 14 deaths (95% prediction interval 7 to 21). CONCLUSION When considering the risk of a subsequent SIDS in a family one should always take into account the known risk factors. If all risks have been identified, then conditional on these risks, the risk of two events is the product of the individual risks. However, for a given family we cannot quantify the magnitude of the increased risk because of other possible risk factors not accounted for in the model.
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Affiliation(s)
- M J Campbell
- Medical Statistics Group, ScHARR, University of Sheffield, Sheffield, UK
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Hopwood V, Lewith G, Prescott P, Campbell MJ. Evaluating the efficacy of acupuncture in defined aspects of stroke recovery: a randomised, placebo controlled single blind study. J Neurol 2008; 255:858-66. [PMID: 18465110 DOI: 10.1007/s00415-008-0790-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 10/15/2007] [Accepted: 10/19/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate the efficacy of acupuncture on stroke recovery compared to an inert placebo. DESIGN Placebo-controlled, randomised, clinical trial. SETTING Post-stroke rehabilitation wards in five NHS hospitals in the UK. SUBJECTS Patients between 4 and 10 days after their first stroke. INTERVENTIONS AND OUTCOME MEASURES The patients received 12 acupuncture or placebo treatments over four weeks. Acupuncture with electrical stimulation was compared with mock TENS, and assessments continued for 12 months after entry. Primary outcome was the Barthel Index (BI). Secondary outcomes were muscle power, Motricity Index (MI), mood, Nottingham Health Profile (NHP) and treatment credibility. RESULTS 92 patients completed data sets. Data were analysed using both t tests and a structural equation based on longitudinal analysis of both BI and MI, using generalised estimating equations with an exchangeable correlation structure. While both acupuncture and placebo (mock TENS) appeared to have had an equal effect on stroke recovery, there is no significant difference between the two interventions at 12 (p = 0.737, 95 % CI -2.00 to 2.81) and 52 weeks (p = 0.371, 95 % CI -3.48 to 1.32). An apparently accelerated improvement in the MI scores in the acupuncture group at 3 weeks (p = 0.009, 95 % CI 1.55 to 10.77) is interesting. CONCLUSIONS Acupuncture did not demonstrate specific efficacy over placebo and both groups did as well as normally expected with this condition.
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Affiliation(s)
- V Hopwood
- University of Southampton, Complementary Medicine Research Unit, Primary Medical Care, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK.
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38
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Abstract
Recurrence of sudden infant death syndrome (SIDS) is rare but may give rise to confusion and controversy because of the differential diagnoses of familial disease or covert homicide. We examine eight studies of recurrent SIDS published in English since 1970. These studies reported relative risks of recurrence, as compared with the population or with controls, ranging from 1.7 to 10.1. We assess the validity of the studies by three main criteria: accuracy of ascertainment, adequacy of investigation and matching of controls. We found that all the studies failed to meet these criteria, and we think that their flaws would have resulted mainly in overestimation of recurrence risk. We conclude that, although an increase in risk is probable on theoretical grounds, this risk cannot be quantified from the available evidence. We suggest that professionals should be cautious in their pronouncements on the chances of recurrence, and that parents who have lost a baby to SIDS can, with the exception of particularly vulnerable families, be reassured that the risk of recurrence is small.
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Affiliation(s)
- C J Bacon
- Glebe House, Danby Wiske, Northallerton, North Yorkshire, UK.
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39
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Davies MJ, Heller S, Skinner TC, Campbell MJ, Carey ME, Cradock S, Dallosso HM, Daly H, Doherty Y, Eaton S, Fox C, Oliver L, Rantell K, Rayman G, Khunti K. Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ 2008. [PMID: 18276664 DOI: 10.1136/bmj.39474.922025.be.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes. DESIGN Multicentre cluster randomised controlled trial in primary care with randomisation at practice level. SETTING 207 general practices in 13 primary care sites in the United Kingdom. PARTICIPANTS 824 adults (55% men, mean age 59.5 years). INTERVENTION A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care. MAIN OUTCOME MEASURES Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months. MAIN RESULTS Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008). CONCLUSION A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis. TRIAL REGISTRATION Current Controlled Trials ISRCTN17844016 [controlled-trials.com].
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Affiliation(s)
- M J Davies
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 5WW.
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40
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Davies MJ, Heller S, Skinner TC, Campbell MJ, Carey ME, Cradock S, Dallosso HM, Daly H, Doherty Y, Eaton S, Fox C, Oliver L, Rantell K, Rayman G, Khunti K. Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ 2008; 336:491-5. [PMID: 18276664 PMCID: PMC2258400 DOI: 10.1136/bmj.39474.922025.be] [Citation(s) in RCA: 542] [Impact Index Per Article: 33.9] [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: 01/19/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes. DESIGN Multicentre cluster randomised controlled trial in primary care with randomisation at practice level. SETTING 207 general practices in 13 primary care sites in the United Kingdom. PARTICIPANTS 824 adults (55% men, mean age 59.5 years). INTERVENTION A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care. MAIN OUTCOME MEASURES Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months. MAIN RESULTS Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008). CONCLUSION A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis. TRIAL REGISTRATION Current Controlled Trials ISRCTN17844016 [controlled-trials.com].
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Affiliation(s)
- M J Davies
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 5WW.
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41
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Davies MJ, Heller S, Skinner TC, Campbell MJ, Carey ME, Cradock S, Dallosso HM, Daly H, Doherty Y, Eaton S, Fox C, Oliver L, Rantell K, Rayman G, Khunti K. Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ 2008. [PMID: 18276664 DOI: 10.1136/bmj.39553.528299.ad] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes. DESIGN Multicentre cluster randomised controlled trial in primary care with randomisation at practice level. SETTING 207 general practices in 13 primary care sites in the United Kingdom. PARTICIPANTS 824 adults (55% men, mean age 59.5 years). INTERVENTION A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care. MAIN OUTCOME MEASURES Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months. MAIN RESULTS Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008). CONCLUSION A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis. TRIAL REGISTRATION Current Controlled Trials ISRCTN17844016 [controlled-trials.com].
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Affiliation(s)
- M J Davies
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 5WW.
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42
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Abstract
The design and analysis of cluster randomized trials has been a recurrent theme in Statistics in Medicine since the early volumes. In celebration of 25 years of Statistics in Medicine, this paper reviews recent developments, particularly those that featured in the journal. Issues in design such as sample size calculations, matched paired designs, cohort versus cross-sectional designs, and practical design problems are covered. Developments in analysis include modification of robust methods to cope with small numbers of clusters, generalized estimation equations, population averaged and cluster specific models. Finally, issues on presenting data, some other clustering issues and the general problem of evaluating complex interventions are briefly mentioned.
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Affiliation(s)
- M J Campbell
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, UK.
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43
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Siyambalapitiya S, Ibbotson V, Doane A, Ghigo E, Campbell MJ, Ross RJ. Combining growth hormone releasing hormone-arginine and synacthen testing diminishes the cortisol response. J Clin Endocrinol Metab 2007; 92:853-6. [PMID: 17192289 DOI: 10.1210/jc.2006-2140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The GHRH/arginine test and short synacthen test (SST) have been validated as safe alternatives to the insulin tolerance test for the assessment of the GH reserve and hypothalamic-pituitary-adrenal axis integrity, respectively. However, these two tests are usually performed separately. The objective was to see whether the synacthen and GHRH/arginine tests could be combined to save time and blood samples and minimize inconvenience to patients. PATIENTS/METHODS Twenty-four consecutive patients with adult onset pituitary disease requiring pituitary function testing were randomized to receive sequentially and in random order a SST, a GHRH/arginine test, and a combined SST and GHRH/arginine test on three different visits separated by at least 1 wk. RESULTS There was no difference in basal cortisol or ACTH values for the SST done alone or during the combined test. However, when GHRH/arginine was given with synacthen, patients had a lower peak cortisol response with a mean difference of 116 nmol/liter (95% confidence interval, 52.54 to 179.37; P < 0.001), and one patient with a normal response on the SST had a subnormal cortisol response in the combined test. Similar lower peak cortisol responses were observed in males and females with combined test. The difference between the peak cortisol responses showed no significant correlation with age (r = 0.123; P = 0.58) or with the body mass index (r = -0.376; P = 0.09). There was no difference in GH measurements between the GHRH/arginine test done alone or in combination with the SST. CONCLUSIONS Combining the SST and GHRH/arginine test results in a lower cortisol response to synacthen. For this reason, the combined test cannot be recommended to assess the integrity of cortisol and GH reserve using current diagnostic criteria.
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Affiliation(s)
- S Siyambalapitiya
- Endocrinology and Reproduction Section, The School of Health and Related Research, University of Sheffield, Sheffield S10 2JF, United Kingdom
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44
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Thomas KJ, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell MJ, Roman M, Walters SJ, Nicholl J. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ 2006; 333:623. [PMID: 16980316 PMCID: PMC1570824 DOI: 10.1136/bmj.38878.907361.7c] [Citation(s) in RCA: 167] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether a short course of traditional acupuncture improves longer term outcomes for patients with persistent non-specific low back pain in primary care. DESIGN Pragmatic, open, randomised controlled trial. SETTING Three private acupuncture clinics and 18 general practices in York, England. PARTICIPANTS 241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration. INTERVENTIONS 10 individualised acupuncture treatments from one of six qualified acupuncturists (160 patients) or usual care only (81 patients). MAIN OUTCOME MEASURES The primary outcome was SF-36 bodily pain, measured at 12 and 24 months. Other outcomes included reported use of analgesics, scores on the Oswestry pain disability index, safety, and patient satisfaction. RESULTS 39 general practitioners referred 289 patients of whom 241 were randomised. At 12 months average SF-36 pain scores increased by 33.2 to 64.0 in the acupuncture group and by 27.9 to 58.3 in the control group. Adjusting for baseline score and for any clustering by acupuncturist, the estimated intervention effect was 5.6 points (95% confidence interval -0.2 to 11.4) at 12 months (n = 213) and 8.0 points (2.8 to 13.2) at 24 months (n = 182). The magnitude of the difference between the groups was about 10%-15% of the final pain score in the control group. Functional disability was not improved. No serious or life threatening events were reported. CONCLUSIONS Weak evidence was found of an effect of acupuncture on persistent non-specific low back pain at 12 months, but stronger evidence of a small benefit at 24 months. Referral to a qualified traditional acupuncturist for a short course of treatment seems safe and acceptable to patients with low back pain. TRIAL REGISTRATION ISRCTN80764175 [controlled-trials.com].
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Affiliation(s)
- K J Thomas
- School of Health and Related Research, University of Sheffield
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45
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Jabrane-Ferrat N, Campbell MJ, Esserman LJ, Peterlin BM. Challenge with mammary tumor cells expressing MHC class II and CD80 prevents the development of spontaneously arising tumors in MMTV-neu transgenic mice. Cancer Gene Ther 2006; 13:1002-10. [PMID: 16841083 DOI: 10.1038/sj.cgt.7700974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [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: 11/08/2022]
Abstract
The HER-2/Neu oncogene has been implicated in human and mouse breast cancer. Indeed, transgenic MMTV-neu mice expressing this oncogene from the mammary tumor virus long terminal repeat develop spontaneous mammary tumors and die within 1 year of life. We have expressed the class II transactivator (CIITA) and/or the costimulatory molecule CD80 (B7.1) in a mammary carcinoma cell line (MCNeuA) derived from these mice. Class II transactivator directs the expression of MHC class II and the machinery for antigen processing and presentation by this pathway. When injected into MMTV-neu mice, tumor cells expressing CD80 or CD80 and CIITA, were rejected completely. In addition, following the rejection of dual expressing cells, 75% of the mice were protected against the development of subsequent spontaneous tumors. Cells expressing only CD80 or CIITA were not as effective as antitumor vaccines in preventing the development of spontaneous tumors. Thus, converting cancer cells into antigen presenting cells could represent an effective immunotherapy for breast cancer.
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MESH Headings
- Animals
- B7-1 Antigen/genetics
- B7-1 Antigen/immunology
- B7-1 Antigen/metabolism
- Blotting, Western
- Cell Line
- Cell Line, Tumor
- Female
- Flow Cytometry
- Genes, MHC Class II/genetics
- Genes, MHC Class II/immunology
- Humans
- Immunohistochemistry
- Immunoprecipitation
- Lymphocytes/immunology
- Mammary Neoplasms, Animal/genetics
- Mammary Neoplasms, Animal/immunology
- Mammary Neoplasms, Animal/pathology
- Mammary Tumor Virus, Mouse/genetics
- Mice
- Mice, Transgenic
- Nuclear Proteins/genetics
- Nuclear Proteins/immunology
- Nuclear Proteins/metabolism
- Rats
- Receptor, ErbB-2/genetics
- Receptor, ErbB-2/immunology
- Receptor, ErbB-2/metabolism
- Trans-Activators/genetics
- Trans-Activators/immunology
- Trans-Activators/metabolism
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Affiliation(s)
- N Jabrane-Ferrat
- Institut de Sciences et Technologies du Medicament de Toulouse, CNRS-Pierre Fabre, Toulouse, France
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46
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Affiliation(s)
- R G Will
- CJD Surveillance Unit, Western General Hospital, Edinburgh, UK
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47
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Goodhart IM, Ibbotson V, Doane A, Roberts B, Campbell MJ, Ross RJM. Hypopituitary patients prefer a touch-screen to paper quality of life questionnaire. Growth Horm IGF Res 2005; 15:384-387. [PMID: 16183313 DOI: 10.1016/j.ghir.2005.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [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: 07/04/2005] [Revised: 08/05/2005] [Accepted: 08/08/2005] [Indexed: 11/28/2022]
Abstract
UNLABELLED Health Related Quality of Life questionnaires are frequently used for research, however only recently has their use been recommended in the routine clinical management of pituitary patients. Questionnaires frequently have complex scoring systems, and may be cumbersome, limiting widespread application. Touch-screen technology can overcome these limitations. We have developed a touch-screen 'Questions on Life Satisfaction-Hypopituitarism' QLS-H (Flash 5 Action script, program design by IG) questionnaire and compared its use and accuracy with a paper version questionnaire in 50 pituitary patients who were attending routine clinics. The HRQoL Z-score for the patient group was lower than the average for the normal UK population, as might be predicted for this patient group. There was no statistically significant difference between scores obtained by the touch-screen and paper questionnaires; mean (SD) Z score was -1.33 (1.4) for touch-screen and -1.26 (1.5) for paper. The touch-screen was preferred by 80% of patients, and quicker to complete (<5min). Additionally, there were significant errors in 14 (28%) of manually scored paper questionnaires. IN CONCLUSION Touch-screen QLS-H questionnaires have advantages over the paper version for the routine clinical assessment of patients with hypopituitarism.
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Affiliation(s)
- I M Goodhart
- The Section of Human Metabolism, University of Sheffield, UK
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48
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Gulliford MC, Adams G, Ukoumunne OC, Latinovic R, Chinn S, Campbell MJ. Intraclass correlation coefficient and outcome prevalence are associated in clustered binary data. J Clin Epidemiol 2005; 58:246-51. [PMID: 15718113 DOI: 10.1016/j.jclinepi.2004.08.012] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2004] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE To describe the association between values for a proportion and the intraclass correlation coefficient (ICC). METHODS Analysis of data obtained from the General Practice Research Database (GPRD) for variation between United Kingdom general practices and results from a Health Technology Assessment (HTA) review for a range of outcomes in community and health services settings. RESULTS There were 188 ICCs from the GPRD, the median prevalence was 13.1% (interquartile range IQR 3.5 to 28.4%) and median ICC 0.051 (IQR 0.011 to 0.094). There were 136 ICCs from the HTA review, with median prevalence 6.5% (IQR 0.4 to 20.7%) and median ICC 0.006 (IQR 0.0003 to 0.036). There was a linear association of log ICC with log prevalence in both datasets (GPRD, regression coefficient 0.61, 95% confidence interval 0.53 to 0.69, P < 0.001; HTA, 0.91, 0.81 to 1.01, P < 0.001). When the prevalence was 1% the predicted ICC was 0.008 from the GPRD or 0.002 from the HTA, but when the prevalence was 40% the predicted ICC was 0.075 (GPRD) or 0.046 (HTA). CONCLUSION The prevalence of an outcome may be used to make an informed assumption about the magnitude of the intraclass correlation coefficient.
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Affiliation(s)
- M C Gulliford
- Department of Public Health Sciences, King's College London, Capital House, 42 Weston St, London SE1 3QD, UK.
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49
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Johnson CD, Toh SKC, Campbell MJ. Combination of APACHE-II score and an obesity score (APACHE-O) for the prediction of severe acute pancreatitis. Pancreatology 2004; 4:1-6. [PMID: 14988652 DOI: 10.1159/000077021] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [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: 04/24/2003] [Accepted: 09/22/2003] [Indexed: 12/11/2022]
Abstract
BACKGROUND The advent of specific therapeutic or preventive treatments for severe acute pancreatitis creates a need to determine the risk of complications for each individual. Scoring systems used in acute pancreatitis identify groups of patients at risk of complications, but the pancreatitis-specific scores require 48 h of hospital admission to give full information. The APACHE-II score is useful within 24 h, but ignores simple clinical features, such as obesity, known to predict severity. The aim of this study was to evaluate a combination of the APACHE-II score with an obesity score in patients with acute pancreatitis, to predict severity using information available during the first 24 h of hospital admission. METHODS Data were collected prospectively from 186 consecutive patients with acute pancreatitis, to allow calculation of the APACHE-II score and body mass index (BMI). BMI was categorised as normal (score = 0), overweight (BMI 26-30: score = 1), or obese (BMI >30: score = 2). A logistic regression model was used to identify factors significantly associated with complications (Atlanta criteria; 104 complications in 60 patients). RESULTS Age, BMI and the acute physiology score independently predicted complications. Addition of the score for obesity to the APACHE-II score gave a composite score (APACHE-O) with greater predictive accuracy. At cut-off of >8, APACHE-O had sensitivity 82%, specificity 86%, positive predictive value 74%, negative predictive value 91% and overall accuracy 85%. CONCLUSIONS This study confirms that age, obesity and APACHE-II measured in the first 24 h of hospital admission can predict complications in acute pancreatitis. Combination of the APACHE-II and obesity scores by simple addition improved categorical prediction of severity (mild or severe) in patients with acute pancreatitis.
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Affiliation(s)
- C D Johnson
- University Surgical Unit, Southampton General Hospital, Southampton, UK.
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50
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Campbell MJ, Woodside JV, Honour JW, Morton MS, Leathem AJC. Effect of red clover-derived isoflavone supplementation on insulin-like growth factor, lipid and antioxidant status in healthy female volunteers: a pilot study. Eur J Clin Nutr 2003; 58:173-9. [PMID: 14679383 DOI: 10.1038/sj.ejcn.1601764] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [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: 11/09/2022]
Abstract
BACKGROUND Isoflavones are estrogen-like plant compounds that may protect against cardiovascular disease and endocrine-responsive cancer. Isoflavones may, because of their ability to act as selective estrogen receptor modulators, alter insulin-like growth factor (IGF) status. OBJECTIVE The aim of this study was to assess the effect of 1-month isoflavone supplementation (86 mg/day red clover-derived isoflavones) on IGF status. DESIGN AND SUBJECTS Healthy pre- (n=16) and postmenopausal (n=7) women were invited to take part in a randomised, placebo-controlled crossover study with a minimum 2-month washout period. RESULTS : For premenopausal subjects, the change in IGF-1, IGF-BP1 and IGF-BP3 assessed at different points of the menstrual cycle did not differ between isoflavone and placebo phase. However, the change in IGF-1, when examined pre- and post-supplementation, was nonsignificantly reduced (P=0.06) on the isoflavone supplement compared to placebo. For postmenopausal subjects, the change in IGF-1, IGF-BP1 and IGFBP-3 concentrations over the supplementation period did not differ between isoflavone or placebo phase. Isoflavones increased HDL in postmenopausal women compared to placebo (P=0.02) but did not alter either cholesterol or triacylglycerol concentrations, and had no effect on antioxidant status. CONCLUSIONS This study shows that 1-month supplementation with red clover isoflavones has a positive effect on HDL cholesterol, but at most a small effect on IGF status in premenopausal and no effect in postmenopausal subjects. Further studies are required to ascertain the role these dietary compounds may have to play in breast cancer prevention.
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Affiliation(s)
- M J Campbell
- Department of Surgery, Royal Free and University College London Medical School, London, UK
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