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Disbeschl SL, Hendry AK, Surgey A, Walker D, Goulden N, Anthony BF, Neal R, Williams NH, Hoare ZSJ, Hiscock J, Edwards RTR, Lewis R, Wilkinson C. 'ThinkCancer!' - Randomised feasibility trial of a novel practice-based early cancer diagnosis intervention. BJGP Open 2024:BJGPO.2023.0220. [PMID: 38702056 DOI: 10.3399/bjgpo.2023.0220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND UK cancer deaths remain high; primary care is key for earlier cancer diagnosis as half of avoidable delays occur here. Improvement is possible through lower referral thresholds, better guideline adherence, and better safety netting systems. Few interventions target whole practice teams. We developed a novel whole practice team intervention to address this. AIM To test the feasibility and acceptability of a novel, complex behavioural intervention 'ThinkCancer!' for assessment in a subsequent Phase III trial. DESIGN & SETTING Pragmatic, superiority pilot RCT with an embedded process evaluation and feasibility economic analysis in Welsh general practices. METHOD Clinical outcome data were collected from practices (the unit of randomisation). Practice characteristics and cancer safety netting systems were assessed. Individual practice staff completed evaluation and feedback forms, and qualitative interviews. The intervention was adapted and refined. RESULTS Trial recruitment and workshop deliveries took place between March 2020 to May 2021. Trial progression criteria for recruitment, intervention fidelity and routine data collection were met. Staff-level fidelity, retention and individual level data collection processes were reviewed and amended. Interviews highlighted positive participant views on all aspects of the intervention. All practices set out to liberalise referral thresholds appropriately, implement guidelines, and address safety netting plans in detail. CONCLUSION 'ThinkCancer!' appears feasible and acceptable; the new iteration of the workshops was completed, and the Phase III trial has been funded to assess the effectiveness and cost effectiveness of this novel professional behaviour change intervention. Delivery at scale to multiple practices will likely improve fidelity and reach.
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Affiliation(s)
- Stefanie Lj Disbeschl
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
| | - Annie K Hendry
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
- North Wales Organisation for Randomised Trials in Health and Social Care (NWORTH CTU), Bangor University, Y Wern, Normal Site, Holyhead Road, Bangor, United Kingdom
| | - Alun Surgey
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
| | - Daniel Walker
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health and Social Care (NWORTH CTU), Bangor University, Y Wern, Normal Site, Holyhead Road, Bangor, United Kingdom
| | - Bethany F Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Ardudwy, Normal Site, Bangor, United Kingdom
| | - Richard Neal
- Department of Health and Community Sciences, Exeter Collaboration for Academic Primary Care, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, United Kingdom
| | - Nefyn H Williams
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Zoë Susannah Jane Hoare
- North Wales Organisation for Randomised Trials in Health and Social Care (NWORTH CTU), Bangor University, Y Wern, Normal Site, Holyhead Road, Bangor, United Kingdom
| | - Julia Hiscock
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
| | - Rhiannon Tudor Rt Edwards
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Ardudwy, Normal Site, Bangor, United Kingdom
| | - Ruth Lewis
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
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Ali A, Aguirre E, Carter J, Hoare S, Brackley K, Goulden N, Hoare Z, Clarke CS, Charlesworth G, Acton D, Spector A. Group cognitive stimulation therapy versus usual care for people with intellectual disabilities and dementia (CST-IDD) in the UK: protocol for a mixed-methods feasibility randomised controlled trial. BMJ Open 2023; 13:e072391. [PMID: 37116994 PMCID: PMC10151918 DOI: 10.1136/bmjopen-2023-072391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION The prevalence of dementia is almost five times higher in people with intellectual disabilities compared with the general population. However, evidence-based treatments for this population are lacking, as most randomised controlled trials for dementia interventions have not included people with intellectual disabilities. Cognitive stimulation therapy (CST) has a robust evidence base in the general dementia population, consistently showing benefits to cognition, quality of life and being cost-effective. We are conducting a mixed-methods feasibility trial of group CST for people with intellectual disabilities and dementia, to determine if a future definitive randomised controlled trial is feasible. METHODS AND ANALYSIS Fifty individuals with intellectual disabilities and dementia will be randomised to either the intervention arm (14 sessions of group CST plus treatment as usual) or the control arm (treatment as usual). Randomisation will occur after informed consent has been obtained and baseline assessments completed. Each arm will have 25 participants, with the intervention arm divided into five or more CST groups with three to five participants in each. The outcomes will be feasibility of recruitment, acceptability and adherence of the intervention, suitability of study outcome measures and feasibility of collecting resource use data. Quantitative and qualitative approaches, including semistructured interviews with group participants, carers and group facilitators, will be employed to assess these outcomes. ETHICS AND DISSEMINATION This study has been approved by Essex REC (Ref: 21/EE/027) and the HRA ethical approval process through the Integrated Research Application System (IRAS ID: 306 756). We plan to publish the results in peer-reviewed journals and conferences as well as provide feedback to funders, sponsors and study participants. TRIAL REGISTRATION NUMBER ISRCTN88614460.
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Affiliation(s)
- Afia Ali
- Unit of Social and Community Psychiatry, East London NHS Foundation Trust, London, UK
| | - Elisa Aguirre
- Psychology Department, Universidad Europea de Madrid, Madrid, Spain
| | - Joanna Carter
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Sarah Hoare
- Research and Development, North East London NHS Foundation Trust, Rainham, UK
| | - Kate Brackley
- Birmingham Research Park, British Institute of Learning Disabilities, Edgbaston, UK
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, Bangor, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, Bangor, UK
| | - Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, London, UK
| | | | - Danny Acton
- Wirral Community Learning Disabilty Team, Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
| | - Aimee Spector
- Department of Clinical, Educational and Health Psychology, University College London, London, UK
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Anthony BF, Disbeschl S, Goulden N, Hendry A, Hiscock J, Hoare Z, Roberts J, Rose J, Surgey A, Williams NH, Walker D, Neal R, Wilkinson C, Edwards RT. Earlier cancer diagnosis in primary care: a feasibility economic analysis of ThinkCancer! BJGP Open 2023; 7:BJGPO.2022.0130. [PMID: 36543386 DOI: 10.3399/bjgpo.2022.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/07/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND UK cancer survival rates are much lower compared with other high-income countries. In primary care, there are opportunities for GPs and other healthcare professionals to act more quickly in response to presented symptoms that might represent cancer. ThinkCancer! is a complex behaviour change intervention aimed at primary care practice teams to improve the timely diagnosis of cancer. AIM To explore the costs of delivering the ThinkCancer! intervention to expedite cancer diagnosis in primary care. DESIGN & SETTING Feasibility economic analysis using a micro-costing approach, which was undertaken in 19 general practices in Wales, UK. METHOD From an NHS perspective, micro-costing methodology was used to determine whether it was feasible to gather sufficient economic data to cost the ThinkCancer! INTERVENTION Owing to the COVID-19 pandemic, ThinkCancer! was mainly delivered remotely online in a digital format. Budget impact analysis (BIA) and sensitivity analysis were conducted to explore the costs of face-to-face delivery of the ThinkCancer! intervention as intended pre-COVID-19. RESULTS The total costs of delivering the ThinkCancer! intervention across 19 general practices in Wales was £25 030, with an average cost per practice of £1317 (standard deviation [SD]: 578.2). Findings from the BIA indicated a total cost of £34 630 for face-to-face delivery. CONCLUSION Data collection methods were successful in gathering sufficient health economics data to cost the ThinkCancer! INTERVENTION Results of this feasibility study will be used to inform a future definitive economic evaluation alongside a pragmatic randomised controlled trial (RCT).
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Affiliation(s)
- Bethany Fern Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Bangor, UK
| | - Stefanie Disbeschl
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | | | - Annie Hendry
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Julia Hiscock
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Zoe Hoare
- NWORTH, Bangor University, Bangor, UK
| | - Jessica Roberts
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Jan Rose
- National Cancer Research Institute (NCRI), Consumer Member, London, UK
| | - Alun Surgey
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Nefyn Howard Williams
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Daniel Walker
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Richard Neal
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Rhiannon Tudor Edwards
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Bangor, UK
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Windle G, Flynn G, Hoare Z, Masterson-Algar P, Egan K, Edwards RT, Jones C, Spector A, Algar-Skaife K, Hughes G, Brocklehurst P, Goulden N, Skelhorn D, Stott J. Effects of an e-health intervention 'iSupport' for reducing distress of dementia carers: protocol for a randomised controlled trial and feasibility study. BMJ Open 2022; 12:e064314. [PMID: 36130751 PMCID: PMC9494593 DOI: 10.1136/bmjopen-2022-064314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION In the UK, National Health Service (NHS) guidelines recommend that informal carers of people living with dementia should be offered training to help them develop care skills and manage their own physical and mental health. The WHO recommends access to affordable, proven, well-designed, online technologies for education, skills training and support for dementia carers. In response to these recommendations, this multisite randomised controlled trial (RCT) is the first study in the UK to evaluate the clinical and cost-effectiveness of an online support programme developed by the WHO called 'iSupport for dementia carers'. METHODS AND ANALYSIS 350 informal carers (age 18+ years) living in Britain who self-identify as experiencing stress and depression will be recruited. They will be randomised to receive 'iSupport', or standardised information about caring for someone with dementia (control-comparison). Data will be collected via videoconferencing (eg, Zoom) or telephone interview at baseline, 3 months and 6 months. Intention-to-treat analysis will ascertain effectiveness in the primary outcomes (distress and depression) and combined cost, and quality-adjusted life-year data will be used to assess cost-effectiveness compared with usual care from a public sector and wider societal perspective. A mixed-methods process evaluation with a subgroup of carers in the intervention (~N=50) will explore the barriers and facilitators to implementing 'iSupport'. A non-randomised feasibility study will adapt 'iSupport' for young carers (n=38 participants, age 11-17 years). ETHICS AND DISSEMINATION The research plan was scrutinised by National Institute for Health Research reviewers ahead of funding being awarded. Ethical approval was granted by Bangor University's School of Health and Medical Sciences Academic Ethics Committee, reference number 2021-16915. Dissemination plans include delivering events for stakeholders, social media, a project website, developing policy briefings, presenting at conferences and producing articles for open access publications. TRIAL REGISTRATION NUMBER ISRCTN17420703.
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Affiliation(s)
- Gill Windle
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Greg Flynn
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Zoe Hoare
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | | | - Kieren Egan
- Department of Computer and Information Science, University of Strathclyde, Glasgow, UK
| | | | - Carys Jones
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Aimee Spector
- Department of Clinical, Educational and Health Psychology, University College London (UCL), London, UK
| | - Katherine Algar-Skaife
- Department of Neuro-medicine and Movement Science (INB), Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Gwenllian Hughes
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Paul Brocklehurst
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Nia Goulden
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Debbie Skelhorn
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Joshua Stott
- Department of Clinical, Educational and Health Psychology, University College London (UCL), London, UK
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Goulden N, Doull I, Kotecha S. Inhaled Corticosteroids and Long-Acting β2 Receptor Agonists for Preterm-Born Children-New Insights but Still Many Questions-Reply. JAMA Pediatr 2022; 176:615-616. [PMID: 35377402 DOI: 10.1001/jamapediatrics.2022.0300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nia Goulden
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, United Kingdom
| | - Iolo Doull
- Department of Paediatrics, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Sailesh Kotecha
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
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Anthony BF, Disbeschl S, Goulden N, Hendry A, Hiscock J, Hoare Z, Lewis R, Roberts J, Rose J, Williams NH, Walker D, Neal R, Wilkinson C, Edwards RT. Improving the diagnosis of cancer in primary care: a feasibility economic analysis of the ThinkCancer! study. Int J Popul Data Sci 2022. [PMCID: PMC8902517 DOI: 10.23889/ijpds.v7i2.1736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Goulden N, Cousins M, Hart K, Jenkins A, Willetts G, Yendle L, Doull I, Williams EM, Hoare Z, Kotecha S. Inhaled Corticosteroids Alone and in Combination With Long-Acting β2 Receptor Agonists to Treat Reduced Lung Function in Preterm-Born Children: A Randomized Clinical Trial. JAMA Pediatr 2022; 176:133-141. [PMID: 34902004 PMCID: PMC8669602 DOI: 10.1001/jamapediatrics.2021.5111] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 07/16/2021] [Accepted: 10/03/2021] [Indexed: 12/05/2022]
Abstract
Importance Decreases in future lung function are a hallmark of preterm birth, but studies for management of decreased lung function are limited. Objective To determine whether 12 weeks of treatment with inhaled corticosteroids (ICS) alone or in combination with long-acting β2 agonists (LABA) improves spirometry and exercise capacity in school-aged preterm-born children who had percent predicted forced expiratory volume in 1 second (%FEV1) less than or equal to 85% compared with inhaled placebo treatment. Design, Setting, and Participants A double-blind, randomized, placebo-controlled trial was conducted to evaluate ICS and ICS/LABA against placebo. Preterm-born children (age, 7-12 years; gestation ≤34 weeks at birth) who did not have clinically significant congenital, cardiopulmonary, or neurodevelopmental abnormalities underwent spirometry, exercise testing, and measurement of fractional exhaled nitric oxide before and after treatment. A total of 144 preterm-born children at the Children's Hospital for Wales in Cardiff, UK, were identified and enrolled between July 1, 2017, and August 31, 2019. Interventions Each child was randomized to 1 of 3 cohorts: fluticasone propionate, 50 μg, with placebo; fluticasone propionate, 50 μg, with salmeterol, 25 μg; or placebo inhalers, all given as 2 puffs twice daily for 12 weeks. Children receiving preexisting ICS treatment underwent washout prior to randomization to ICS or ICS/LABA. Main Outcomes and Measures The primary outcome was between-group differences assessed by adjusted pretreatment and posttreatment differences of %FEV1 using analysis of covariance. Intention-to-treat analysis was conducted. Results Of 144 preterm-born children who were identified with %FEV1 less than or equal to 85%, 53 were randomized. Treatment allocation was 20 children receiving ICS (including 5 with prerandomization ICS), 19 children receiving ICS/LABA (including 4 with prerandomization ICS), and 14 children receiving placebo. The mean (SD) age of children was 10.8 (1.2) years, and 29 of the randomized children (55%) were female. The posttreatment %FEV1 was adjusted for sex, gestation, bronchopulmonary dysplasia, intrauterine growth restriction, pretreatment corticosteroid status, treatment group, and pretreatment values. Posttreatment adjusted means for %FEV1, using analysis of covariance, were 7.7% (95% CI, -0.27% to 15.72%; P = .16) higher in the ICS group and 14.1% (95% CI, 7.3% to 21.0%; P = .002) higher in the ICS/LABA group compared with the placebo group. Active treatment decreased the fractional exhaled nitric oxide and improved postexercise bronchodilator response but did not improve exercise capacity. One child developed cough when starting inhaler treatment; no other adverse events reported during the trial could be attributed to the inhaler treatment. Conclusions and Relevance The results of this randomized clinical trial suggest that combined ICS/LABA treatment is beneficial for prematurity-associated lung disease in children. Trial Registration EudraCT number: 2015-003712-20.
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Affiliation(s)
- Nia Goulden
- NWORTH, Bangor University, Bangor, United Kingdom
| | - Michael Cousins
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Kylie Hart
- Department of Paediatrics, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | | | - Gill Willetts
- Department of Paediatrics, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Louise Yendle
- Department of Paediatrics, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Iolo Doull
- Department of Paediatrics, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - E. Mark Williams
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, United Kingdom
| | - Zoe Hoare
- NWORTH, Bangor University, Bangor, United Kingdom
| | - Sailesh Kotecha
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
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Tsakos G, Brocklehurst PR, Watson S, Verey A, Goulden N, Jenkins A, Hoare Z, Pye K, Wassall RR, Sherriff A, Heilmann A, O'Neill C, Smith CJ, Langley J, Venturelli R, Cairns P, Lievesley N, Watt RG, Kee F, McKenna G. Improving the oral health of older people in care homes (TOPIC): a protocol for a feasibility study. Pilot Feasibility Stud 2021; 7:138. [PMID: 34215322 PMCID: PMC8249429 DOI: 10.1186/s40814-021-00872-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 06/11/2021] [Indexed: 11/21/2022] Open
Abstract
Background Evidence for interventions promoting oral health amongst care home residents is weak. The National Institute for Health and Care Excellence (NICE) guideline NG48 aims to maintain and improve the oral health of care home residents. A co-design process that worked with residents and care home staff to understand how the NG48 guideline could be best implemented in practice has been undertaken to refine a complex intervention. The aim of this study is to assess the feasibility of the intervention to inform a future larger scale definitive trial. Methods This is a protocol for a pragmatic cluster randomised controlled trial with a 12-month follow-up that will be undertaken in 12 care homes across two sites (six in London, six in Northern Ireland). Care homes randomised to the intervention arm (n = 6) will receive the complex intervention based on the NG48 guideline, whilst care homes randomised to the control arm (n = 6) will continue with routine practice. The intervention will include a training package for care home staff to promote knowledge and skills in oral health promotion, the use of the Oral Health Assessment Tool on residents by trained care home staff, and a ‘support worker assisted’ daily tooth-brushing regime with toothpaste containing 1500 ppm fluoride. An average of ten residents, aged 65 years or over who have at least one natural tooth, will be recruited in each care home resulting in a recruited sample of 120 participants. Assessments will be undertaken at baseline, 6 months and 12 months, and will include a dental examination and questionnaires on general health and oral health administered by a research assistant. A parallel process evaluation involving semi-structured interviews will be undertaken to explore how the intervention could be embedded in standard practice. Rates of recruitment and retention, and intervention fidelity will also be recorded. A cost-consequence model will determine the relevance of different outcome measures in the decision-making context. Discussion The study will provide valuable information for trialists, policymakers, clinicians and care home staff on the feasibility and associated costs of oral health promotion in UK care homes. Trial registration ISRCTN10276613. Registered on 17th April 2020. http://www.isrctn.com/ISRCTN10276613.
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Affiliation(s)
- Georgios Tsakos
- Department of Epidemiology and Public Health, University College London, London, UK
| | | | - Sinead Watson
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.
| | - Anna Verey
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Nia Goulden
- NWORTH Clinical Trials Unit, Bangor University, Bangor, UK
| | - Alison Jenkins
- NWORTH Clinical Trials Unit, Bangor University, Bangor, UK
| | - Zoe Hoare
- NWORTH Clinical Trials Unit, Bangor University, Bangor, UK
| | - Kirstie Pye
- NWORTH Clinical Trials Unit, Bangor University, Bangor, UK
| | | | | | - Anja Heilmann
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Ciaran O'Neill
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Craig J Smith
- Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK.,Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal Foundation NHS Trust, Salford, UK
| | - Joe Langley
- Art and Design Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Renato Venturelli
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Peter Cairns
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.,BELONG PPI Group, Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Nat Lievesley
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.,Centre for Policy on Ageing, London, UK
| | - Richard G Watt
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Frank Kee
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Gerald McKenna
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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Disbeschl S, Surgey A, Roberts JL, Hendry A, Lewis R, Goulden N, Hoare Z, Williams N, Anthony BF, Edwards RT, Law RJ, Hiscock J, Carson-Stevens A, Neal RD, Wilkinson C. Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales. Pilot Feasibility Stud 2021; 7:100. [PMID: 33883033 PMCID: PMC8059131 DOI: 10.1186/s40814-021-00834-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/07/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial. METHODS The ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation. DISCUSSION This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial. TRIAL REGISTRATION ClinicalTrials.gov NCT04823559 .
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Affiliation(s)
- Stefanie Disbeschl
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK.
| | - Alun Surgey
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Jessica L Roberts
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Annie Hendry
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Nefyn Williams
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, L69 3GL, UK
| | - Bethany Fern Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Rhiannon Tudor Edwards
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Rebecca-Jane Law
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Julia Hiscock
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, UHW Main Building, Heath Park, Cardiff, CF14 4XN, UK
| | - Richard D Neal
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL, UK
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
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10
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Poolman M, Roberts J, Wright S, Hendry A, Goulden N, Holmes EA, Byrne A, Perkins P, Hoare Z, Nelson A, Hiscock J, Hughes D, O'Connor J, Foster B, Reymond L, Healy S, Lewis P, Wee B, Johnstone R, Roberts R, Parkinson A, Roberts S, Wilkinson C. Carer administration of as-needed subcutaneous medication for breakthrough symptoms in people dying at home: the CARiAD feasibility RCT. Health Technol Assess 2020; 24:1-150. [PMID: 32484432 DOI: 10.3310/hta24250] [Citation(s) in RCA: 4] [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] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Most people who are dying want to be cared for at home, but only half of them achieve this. The likelihood of a home death often depends on the availability of able and willing lay carers. When people who are dying are unable to take oral medication, injectable medication is used. When top-up medication is required, a health-care professional travels to the dying person's home, which may delay symptom relief. The administration of subcutaneous medication by lay carers, although not widespread UK practice, has proven to be key in achieving better symptom control for those dying at home in other countries. OBJECTIVES To determine if carer administration of as-needed subcutaneous medication for common breakthrough symptoms in people dying at home is feasible and acceptable in the UK, and if it would be feasible to test this intervention in a future definitive randomised controlled trial. DESIGN We conducted a two-arm, parallel-group, individually randomised, open pilot trial of the intervention versus usual care, with a 1 : 1 allocation ratio, using convergent mixed methods. SETTING Home-based care without 24/7 paid care provision, in three UK sites. PARTICIPANTS Participants were dyads of adult patients and carers: patients in the last weeks of their life who wished to die at home and lay carers who were willing to be trained to give subcutaneous medication. Strict risk assessment criteria needed to be met before approach, including known history of substance abuse or carer ability to be trained to competency. INTERVENTION Intervention-group carers received training by local nurses using a manualised training package. MAIN OUTCOME MEASURES Quantitative data were collected at baseline and 6-8 weeks post bereavement and via carer diaries. Interviews with carers and health-care professionals explored attitudes to, experiences of and preferences for giving subcutaneous medication and experience of trial processes. The main outcomes of interest were feasibility, acceptability, recruitment rates, attrition and selection of the most appropriate outcome measures. RESULTS In total, 40 out of 101 eligible dyads were recruited (39.6%), which met the feasibility criterion of recruiting > 30% of eligible dyads. The expected recruitment target (≈50 dyads) was not reached, as fewer than expected participants were identified. Although the overall retention rate was 55% (22/40), this was substantially unbalanced [30% (6/20) usual care and 80% (16/20) intervention]. The feasibility criterion of > 40% retention was, therefore, considered not met. A total of 12 carers (intervention, n = 10; usual care, n = 2) and 20 health-care professionals were interviewed. The intervention was considered acceptable, feasible and safe in the small study population. The context of the feasibility study was not ideal, as district nurses were seriously overstretched and unfamiliar with research methods. A disparity in readiness to consider the intervention was demonstrated between carers and health-care professionals. Findings showed that there were methodological and ethics issues pertaining to researching last days of life care. CONCLUSION The success of a future definitive trial is uncertain because of equivocal results in the progression criteria, particularly poor recruitment overall and a low retention rate in the usual-care group. Future work regarding the intervention should include understanding the context of UK areas where this has been adopted, ascertaining wider public views and exploring health-care professional views on burden and risk in the NHS context. There should be consideration of the need for national policy and of the most appropriate quantitative outcome measures to use. This will help to ascertain if there are unanswered questions to be studied in a trial. TRIAL REGISTRATION Current Controlled Trials ISRCTN11211024. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 25. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | | | - Stella Wright
- School of Health Sciences, Bangor University, Bangor, UK
| | - Annie Hendry
- School of Health Sciences, Bangor University, Bangor, UK
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | | | - Anthony Byrne
- Marie Curie Research Centre, School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Perkins
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK.,Sue Ryder Leckhampton Court Hospice, Cheltenham, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | - Annmarie Nelson
- Marie Curie Research Centre, School of Medicine, Cardiff University, Cardiff, UK
| | - Julia Hiscock
- School of Health Sciences, Bangor University, Bangor, UK
| | - Dyfrig Hughes
- School of Health Sciences, Bangor University, Bangor, UK
| | | | - Betty Foster
- Public Contributor, North Wales Cancer Patient Forum, North Wales Cancer Treatment Centre, Bodelwyddan, UK
| | - Liz Reymond
- Brisbane South Palliative Care Collaborative, School of Medicine, Griffith University, Southport, QLD, Australia
| | - Sue Healy
- Metro South Palliative Care Service, Brisbane, QLD, Australia
| | - Penney Lewis
- Centre for Medical Law and Ethics, King's College London, London, UK
| | - Bee Wee
- Harris Manchester College, University of Oxford, Oxford, UK
| | | | | | | | - Sian Roberts
- Betsi Cadwaladr University Health Board, Bangor, UK
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11
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Williams NH, Jenkins A, Goulden N, Hoare Z, Hughes DA, Wood E, Foster NE, Walsh D, Carnes D, Sparkes V, Hay EM, Isaacs J, Konstantinou K, Morrissey D, Karppinen J, Genevay S, Wilkinson C. Lessons learnt from a discontinued randomised controlled trial: adalimumab injection compared with placebo for patients receiving physiotherapy treatment for sciatica (Subcutaneous Injection of Adalimumab Trial compared with Control: SCIATiC). Trials 2018; 19:408. [PMID: 30064491 PMCID: PMC6069989 DOI: 10.1186/s13063-018-2801-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 07/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adalimumab, a biological treatment targeting tumour necrosis factor α, might be useful in sciatica. This paper describes the challenges faced when developing a new treatment pathway for a randomised controlled trial of adalimumab for people with sciatica, as well as the reasons why the trial discussed was stopped early. METHODS A pragmatic, parallel group, randomised controlled trial with blinded (masked) participants, clinicians, outcome assessment and statistical analysis was conducted in six UK sites. Participants were identified and recruited from general practices, musculoskeletal services and outpatient physiotherapy clinics. They were adults with persistent symptoms of sciatica of 1 to 6 months' duration with moderate to high level of disability. Eligibility was assessed by research physiotherapists according to clinical criteria, and participants were randomised to receive two doses of adalimumab (80 mg then 40 mg 2 weeks later) or saline placebo subcutaneous injections in the posterior lateral thigh. Both groups were referred for a course of physiotherapy. Outcomes were measured at baseline, 6-week, 6-month and 12-month follow-up. The main outcome measure was disability measured using the Oswestry Disability Index. The planned sample size was 332, with the first 50 in an internal pilot phase. RESULTS The internal pilot phase was discontinued after 10 months from opening owing to low recruitment (two of the six sites active, eight participants recruited). There were several challenges: contractual delays; one site did not complete contract negotiations, and two sites signed contracts shortly before trial closure; site withdrawal owing to patient safety concerns; difficulties obtaining excess treatment costs; and in the two sites that did recruit, recruitment was slower than planned because of operational issues and low uptake by potential participants. CONCLUSIONS Improved patient care requires robust clinical research within contexts in which treatments can realistically be provided. Step changes in treatment, such as the introduction of biologic treatments for severe sciatica, raise complex issues that can delay trial initiation and retard recruitment. Additional preparatory work might be required before testing novel treatments. A randomised controlled trial of tumour necrosis factor-α blockade is still needed to determine its cost-effectiveness in severe sciatica. TRIAL REGISTRATION Current Controlled Trials, ISRCTN14569274 . Registered on 15 December 2014.
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Affiliation(s)
- Nefyn H. Williams
- Department of Health Services Research, University of Liverpool, Waterhouse Block B, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Alison Jenkins
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Nia Goulden
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Zoe Hoare
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | | | - Eifiona Wood
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Nadine E. Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - David Walsh
- Arthritis Research UK Pain Centre and National Institute for Health Research Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Dawn Carnes
- Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, London, UK
| | - Valerie Sparkes
- School of Healthcare Science, Cardiff University, Cardiff, UK
| | - Elaine M. Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - John Isaacs
- National Institute for Health Research Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Dylan Morrissey
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jaro Karppinen
- Medical Research Centre Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | | | - Clare Wilkinson
- School of Healthcare Sciences, Bangor University, Bangor, UK
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12
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Kinderman P, Butchard S, Bruen AJ, Wall A, Goulden N, Hoare Z, Jones C, Edwards R. A randomised controlled trial to evaluate the impact of a human rights based approach to dementia care in inpatient ward and care home settings. Health Serv Deliv Res 2018. [DOI: 10.3310/hsdr06130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAlthough it is widely recognised that adopting a person-centred approach is beneficial in the care of people living with dementia, a gap remains between the rhetoric and the reality of quality care. Some widely adopted care practices can result in the personhood of this group being threatened and their human rights being undermined.ObjectivesTo evaluate the impact of applying a human rights based approach in dementia inpatient wards and care homes on the quality of care delivered and the well-being of the person living with dementia.DesignA cluster randomised design was employed to compare the impact of implementing a human rights based approach intervention (i.e. training, applying the ‘Getting It Right’ assessment tool and receiving booster sessions) at 10 intervention sites with 10 control sites.SettingEight NHS dementia inpatient wards and 12 care homes in the north-west of England.ParticipantsPeople living with dementia who were residing on dementia inpatient wards or in care homes, and staff working at these sites. The aim was to recruit 280 people living with dementia.InterventionsA sample of staff (an average of 8.9 per site) at each of the sites was trained in a human rights based approach to care, including the application of the ‘Getting It Right’ assessment tool. The tool was then introduced at the site and monthly booster sessions were delivered.Main outcome measuresThe primary outcome measure used in the research was the Quality of Life in Alzheimer’s Disease scale to assess the subjective well-being of the person with dementia. Secondary outcome measures included measures of the quality of care provided (dementia care mapping) and direct measures of the effectiveness of the training in increasing knowledge of and attitudes towards human rights. The study also included an economic evaluation utilising the EuroQol-5 Dimensions, three-level version, and the Adult Social Care Outcomes Toolkit measure.ResultsThe study recruited 439 people living with dementia: 213 to the intervention arm and 226 to the control arm. Primary outcome data were analysed using a linear mixed model. There were no significant differences found in the reported quality of life of residents between the control and intervention groups after the intervention [F(1,16.51) = 3.63;p = 0.074]. The mean difference between the groups was 1.48 (95% confidence interval –7.86 to 10.82).ConclusionsDespite the fact that the training increased staff knowledge of and positive attitudes towards human rights, and although there were some changes in staff decision-making strategies in clinical situations, there was no change in the quality of care provided or in the reported well-being of people living with dementia in these settings. This led to questions about the efficacy of training in bringing about cultural change and improving care practices.LimitationsThere was limited uptake of the training and booster sessions that were integral to the intervention.Future workFuture work could usefully focus on understanding the difficulty in translating change in attitude and knowledge into behaviour.Trial registrationCurrent Controlled Trials ISRCTN94553028.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Peter Kinderman
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | | | - Ashley J Bruen
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Abbie Wall
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health (NWORTH), School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health (NWORTH), School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Carys Jones
- Centre for Health Economics and Medicines Evaluation, Institute of Medical and Social Care Research, Bangor University, Bangor, UK
| | - Rhiannon Edwards
- Centre for Health Economics and Medicines Evaluation, Institute of Medical and Social Care Research, Bangor University, Bangor, UK
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13
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Eiser C, Stride CB, Vora A, Goulden N, Mitchell C, Buck G, Adams M, Jenney MEM. Prospective evaluation of quality of life in children treated in UKALL 2003 for acute lymphoblastic leukaemia: A cohort study. Pediatr Blood Cancer 2017; 64. [PMID: 28475268 DOI: 10.1002/pbc.26615] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 03/19/2017] [Accepted: 03/27/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Health-related quality of life (HRQoL) from diagnosis until end of treatment for children with acute lymphoblastic leukaemia was investigated, examining effects of age, gender, risk-stratified treatment regimen, and therapy intensity (one vs. two 'delayed intensifications' [DIs]). METHOD In a multi-centre prospective study, parents reported their child's generic and disease-specific HRQoL and their own care-giving burden at five time points. From 1,428 eligible patients, 874 parents completed questionnaires at least once during treatment. RESULTS At each time point, generic HRQoL was significantly lower than equivalent norm scores for healthy children. HRQoL decreased significantly at the start of treatment, before recovering gradually (but remained below pre-treatment levels). Parents reported that older children worried more about side effects and their appearance, but showed less procedural anxiety than younger children. Concern for appearance was greater among girls than boys. Compared to Regimen B (i.e. additional doxorubicin during induction and additional cyclophosphamide and cytarabine during consolidation chemotherapy), patients receiving Regimen A had fewer problems with pain and nausea. There were no statistically significant differences in HRQoL by number of DI blocks received. INTERPRETATION HRQoL is compromised at all stages of treatment, and is partly dependent on age. The findings increase understanding of the impact of therapy on children's HRQoL and parental care-giving burden, and will contribute to the design of future trials.
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Affiliation(s)
- C Eiser
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom
| | - C B Stride
- Department of statistics, Management School, Conduit Road, University of Sheffield, Sheffield, United Kingdom
| | - A Vora
- Department of Paediatric Haematology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, United Kingdom
| | - N Goulden
- Department of paediatric haematology, Great Ormond Street Hospital, London, United Kingdom
| | - C Mitchell
- Department of Paediatric Haematology/Oncology, John Radcliffe Hospital, Oxford, United Kingdom
| | - G Buck
- Clinical Trial Service Unit, University of Oxford, Oxford, United Kingdom
| | - M Adams
- Department of Paediatric Oncology, Children's Hospital for Wales, Heath Park, Cardiff, United Kingdom
| | - M E M Jenney
- Department of Paediatric Oncology, Children's Hospital for Wales, Heath Park, Cardiff, United Kingdom
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14
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Subbe CP, Goulden N, Mawdsley K, Smith R. Anticipating care needs of patients after discharge from hospital: Frail and elderly patients without physiological abnormality on day of admission are more likely to require social services input. Eur J Intern Med 2017; 45:74-77. [PMID: 28974330 DOI: 10.1016/j.ejim.2017.09.029] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 09/13/2017] [Accepted: 09/23/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Acute admissions to hospital are rising. As a part of a service evaluation we examined pathways of patients following hospital discharge depending on data available on admission to hospital. METHODS We merged data available on admission to the Wrexham Maelor hospital from an existing data-base in the Acute Medical Unit with follow up data from local social services as part of a data sharing agreement. Patients requiring support by social services post-discharge were matched with patients not requiring social services from the same post-code. RESULTS Stepwise logistic regression analysis identified candidate variables predicting likely support need. Decision tree analysis identified sub-groups of patients with higher likelihood to require support by social services after discharge from hospital. We found patients with normal physiology on admission as evidenced by a value of zero for the National Early Warning Score who were frail or older than 85years were most likely to require support after discharge. CONCLUSIONS Information available on admission to hospital might inform long term care needs. Prospective testing is needed. The algorithms are prone to be dependent on availability of local services but our methodology is expected to be transferable to other organizations.
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Affiliation(s)
- C P Subbe
- Acute, Respiratory & Critical Care Medicine, Ysbyty Gwynedd, United Kingdom; School of Medical Sciences, Bangor University, Bangor LL57 2AS, United Kingdom.
| | - N Goulden
- North Wales Organisation for Randomised Trials in Health, School of Healthcare Sciences, Bangor University, Bangor LL57 2PZ, United Kingdom
| | - K Mawdsley
- North Wales Organisation for Randomised Trials in Health, School of Healthcare Sciences, Bangor University, Bangor LL57 2PZ, United Kingdom
| | - R Smith
- Wrexham County Borough Council, Guildhall, Wrexham LL11 1AY, United Kingdom
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15
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Williams NH, Jenkins A, Goulden N, Hoare Z, Hughes DA, Wood E, Foster NE, Walsh DA, Carnes D, Sparkes V, Hay EM, Isaacs J, Konstantinou K, Morrissey D, Karppinen J, Genevay S, Wilkinson C. Subcutaneous Injection of Adalimumab Trial compared with Control (SCIATiC): a randomised controlled trial of adalimumab injection compared with placebo for patients receiving physiotherapy treatment for sciatica. Health Technol Assess 2017; 21:1-180. [PMID: 29063827 DOI: 10.3310/hta21600] [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: 01/23/2023] Open
Abstract
BACKGROUND Biological treatments such as adalimumab (Humira®; AbbVie Ltd, Maidenhead, UK) are antibodies targeting tumour necrosis factor alpha, released from ruptured intervertebral discs, which might be useful in sciatica. Recent systematic reviews concluded that they might be effective, but that a definitive randomised controlled trial was needed. Usual care in the NHS typically includes a physiotherapy intervention. OBJECTIVES To test whether or not injections of adalimumab plus physiotherapy are more clinically effective and cost-effective than injections of saline plus physiotherapy for patients with sciatica. DESIGN Pragmatic, parallel-group, randomised controlled trial with blinded participants and clinicians, and an outcome assessment and statistical analysis with concurrent economic evaluation and internal pilot. SETTING Participants were referred from primary care and musculoskeletal services to outpatient physiotherapy clinics. PARTICIPANTS Adults with persistent symptoms of sciatica of 1-6 months' duration and with moderate to high levels of disability. Eligibility was assessed by research physiotherapists according to clinical criteria for diagnosing sciatica. INTERVENTIONS After a second eligibility check, trial participants were randomised to receive two doses of adalimumab (80 mg and then 40 mg 2 weeks later) or saline injections. Both groups were referred for a course of physiotherapy. MAIN OUTCOME MEASURES Outcomes were measured at the start, and after 6 weeks' and 6 months' follow-up. The main outcome measure was the Oswestry Disability Index (ODI). Other outcomes: leg pain version of the Roland-Morris Disability Questionnaire, Sciatica Bothersomeness Index, EuroQol-5 Dimensions, 5-level version, Hospital Anxiety and Depression Scale, resource use, risk of persistent disabling pain, pain trajectory based on a single question, Pain Self-Efficacy Questionnaire, Tampa Scale of Kinesiophobia and adverse effects. SAMPLE SIZE To detect an effect size of 0.4 with 90% power, a 5% significance level for a two-tailed t-test and 80% retention rate, 332 participants would have needed to be recruited. ANALYSIS PLAN The primary effectiveness analysis would have been linear mixed models for repeated measures to measure the effects of time and group allocation. An internal pilot study would have involved the first 50 participants recruited across all centres. The primary economic analysis would have been a cost-utility analysis. RESULTS The internal pilot study was discontinued as a result of low recruitment after eight participants were recruited from two out of six sites. One site withdrew from the study before recruitment started, one site did not complete contract negotiations and two sites signed contracts shortly before trial closure. In the two sites that did recruit participants, recruitment was slow. This was partly because of operational issues, but also because of a low rate of uptake from potential participants. LIMITATIONS Although large numbers of invitations were sent to potential participants, identified by retrospective searches of general practitioner (GP) records, there was a low rate of uptake. Two sites planned to recruit participants during GP consultations but opened too late to recruit any participants. CONCLUSION The main failure was attributable to problems with contracts. Because of this we were not able to complete the internal pilot or to test all of the different methods for primary care recruitment we had planned. A trial of biological therapy in patients with sciatica still needs to be done, but would require a clearer contracting process, qualitative research to ensure that patients would be willing to participate, and simpler recruitment methods. TRIAL REGISTRATION Current Controlled Trials ISRCTN14569274. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 60. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nefyn H Williams
- School of Healthcare Sciences, Bangor University, Bangor, UK.,Betsi Cadwaladr University Health Board, Bangor, UK
| | - Alison Jenkins
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Nia Goulden
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Zoe Hoare
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Dyfrig A Hughes
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Eifiona Wood
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Nadine E Foster
- Research Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - David A Walsh
- Arthritis Research UK Pain Centre Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, UK
| | - Dawn Carnes
- Centre for Primary Care and Public Health, Bart's and the London School of Medicine and Dentistry, London, UK
| | - Valerie Sparkes
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Elaine M Hay
- Research Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - John Isaacs
- National Institute for Health Research Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Kika Konstantinou
- Research Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Dylan Morrissey
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jaro Karppinen
- Medical Research Centre Oulu, University of Oulu, Oulu, Finland
| | - Stephane Genevay
- Rheumatology Department, Geneva University Hospitals, Geneva, Switzerland
| | - Clare Wilkinson
- School of Healthcare Sciences, Bangor University, Bangor, UK
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16
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Rossig C, Pule M, Altvater B, Saiagh S, Wright G, Ghorashian S, Clifton-Hadley L, Champion K, Sattar Z, Popova B, Hackshaw A, Smith P, Roberts T, Biagi E, Dreno B, Rousseau R, Kailayangiri S, Ahlmann M, Hough R, Kremens B, Sauer MG, Veys P, Goulden N, Cummins M, Amrolia PJ. Vaccination to improve the persistence of CD19CAR gene-modified T cells in relapsed pediatric acute lymphoblastic leukemia. Leukemia 2017; 31:1087-1095. [PMID: 28126984 DOI: 10.1038/leu.2017.39] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [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] [Received: 08/17/2016] [Revised: 11/21/2016] [Accepted: 01/05/2017] [Indexed: 12/23/2022]
Abstract
Trials with second generation CD19 chimeric antigen receptors (CAR) T-cells report unprecedented responses but are associated with risk of cytokine release syndrome (CRS). Instead, we studied the use of donor Epstein-Barr virus-specific T-cells (EBV CTL) transduced with a first generation CD19CAR, relying on the endogenous T-cell receptor for proliferation. We conducted a multi-center phase I/II study of donor CD19CAR transduced EBV CTL in pediatric acute lymphoblastic leukaemia (ALL). Patients were eligible pre-emptively if they developed molecular relapse (>5 × 10-4) post first stem cell transplant (SCT), or prophylactically post second SCT. An initial cohort showed poor expansion/persistence. We therefore investigated EBV-directed vaccination to enhance expansion/persistence. Eleven patients were treated. No CRS, neurotoxicity or graft versus host disease (GVHD) was observed. At 1 month, 5 patients were in CR (4 continuing, 1 de novo), 1 PR, 3 had stable disease and 3 no response. At a median follow-up of 12 months, 10 of 11 have relapsed, 2 are alive with disease and 1 alive in CR 3 years. Although CD19CAR CTL expansion was poor, persistence was enhanced by vaccination. Median persistence was 0 (range: 0-28) days without vaccination compared to 56 (range: 0-221) days with vaccination (P=0.06). This study demonstrates the feasibility of multi-center studies of CAR T cell therapy and the potential for enhancing persistence with vaccination.
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MESH Headings
- Antigens, CD19
- Child
- Child, Preschool
- Chimera
- Female
- Herpesvirus 4, Human
- Humans
- Immunotherapy/methods
- Immunotherapy, Adoptive
- Male
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy
- Receptors, Antigen, T-Cell/genetics
- Receptors, Antigen, T-Cell/immunology
- Recurrence
- T-Lymphocytes, Cytotoxic/transplantation
- T-Lymphocytes, Cytotoxic/virology
- Vaccination
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Affiliation(s)
- C Rossig
- Department of Pediatric Hematology and Oncology, University Children's Hospital, Münster, Germany
| | - M Pule
- Department of Haematology, Cancer Institute, University College London, London, UK
| | - B Altvater
- Department of Pediatric Hematology and Oncology, University Children's Hospital, Münster, Germany
| | - S Saiagh
- Unite de Therapie Cellulaire et Genetique, CHU Nantes, Nantes, France
| | - G Wright
- Department of Paediatric Haematology and Bone Marrow Transplant, Molecular and Cellular Immunology, UCL Great Ormond Street Institute of Child Health, London, UK
| | - S Ghorashian
- Molecular and Cellular Immunology Section, Institute of Child Health, University College London, London, UK
| | | | - K Champion
- Cancer Research UK and UCL Cancer Trials Centre, London, UK
| | - Z Sattar
- Cancer Research UK and UCL Cancer Trials Centre, London, UK
| | - B Popova
- Cancer Research UK and UCL Cancer Trials Centre, London, UK
| | - A Hackshaw
- Cancer Research UK and UCL Cancer Trials Centre, London, UK
| | - P Smith
- Cancer Research UK and UCL Cancer Trials Centre, London, UK
| | - T Roberts
- Cancer Research UK and UCL Cancer Trials Centre, London, UK
| | - E Biagi
- Clinica Pediatrica, Università Milano Bicocca, Osp. San Gerardo/Fondazione MBBM, Monza, Italy
| | - B Dreno
- Unite de Therapie Cellulaire et Genetique, CHU Nantes, Nantes, France
| | - R Rousseau
- Department of Pediatric Haemato-Oncology, Centre Leon Berard, Lyon, France
| | - S Kailayangiri
- Department of Pediatric Hematology and Oncology, University Children's Hospital, Münster, Germany
| | - M Ahlmann
- Department of Pediatric Hematology and Oncology, University Children's Hospital, Münster, Germany
| | - R Hough
- Department of Haematology, Cancer Institute, University College London, London, UK
| | - B Kremens
- Department of Pediatric Hematology and Oncology, University Children's Hospital Essen, Essen, Germany
| | - M G Sauer
- Department of Pediatric Hematology/Oncology, Hannover Medical School, Hannover, Germany
| | - P Veys
- Department of Paediatric Haematology and Bone Marrow Transplant, Molecular and Cellular Immunology, UCL Great Ormond Street Institute of Child Health, London, UK
| | - N Goulden
- Department of Paediatric Haematology and Bone Marrow Transplant, Molecular and Cellular Immunology, UCL Great Ormond Street Institute of Child Health, London, UK
| | - M Cummins
- Department of Bone Marrow Transplant, Bristol Royal Hospital for Children, Bristol, UK
| | - P J Amrolia
- Department of Paediatric Haematology and Bone Marrow Transplant, Molecular and Cellular Immunology, UCL Great Ormond Street Institute of Child Health, London, UK
- Molecular and Cellular Immunology Section, Institute of Child Health, University College London, London, UK
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Sundaresh A, Gasparoli L, Mangolini M, Edwards D, Hubank M, Brooks T, Bartram J, Goulden N, Ancliff P, de Boer J, Williams O. Aberrant transcriptional pathways in t(12;21) Acute Lymphoblastic Leukemia. Klin Padiatr 2016. [DOI: 10.1055/s-0036-1582489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Jenkinson S, Kirkwood AA, Goulden N, Vora A, Linch DC, Gale RE. Impact of PTEN abnormalities on outcome in pediatric patients with T-cell acute lymphoblastic leukemia treated on the MRC UKALL2003 trial. Leukemia 2016; 30:39-47. [PMID: 26220040 PMCID: PMC4705426 DOI: 10.1038/leu.2015.206] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/29/2015] [Accepted: 07/22/2015] [Indexed: 12/21/2022]
Abstract
PTEN gene inactivation by mutation or deletion is common in pediatric T-cell acute lymphoblastic leukemia (T-ALL), but the impact on outcome is unclear, particularly in patients with NOTCH1/FBXW7 mutations. We screened samples from 145 patients treated on the MRC UKALL2003 trial for PTEN mutations using heteroduplex analysis and gene deletions using single nucleotide polymorphism arrays, and related genotype to response to therapy and long-term outcome. PTEN loss-of-function mutations/gene deletions were detected in 22% (PTEN(ABN)). Quantification of mutant level indicated that 67% of mutated cases harbored more than one mutant, with up to four mutants detected, consistent with the presence of multiple leukemic sub-clones. Overall, 41% of PTEN(ABN) cases were considered to have biallelic abnormalities (mutation and/or deletion) with complete loss of PTEN in a proportion of cells. In addition, 9% of cases had N- or K-RAS mutations. Neither PTEN nor RAS genotype significantly impacted on response to therapy or long-term outcome, irrespective of mutant level, and there was no evidence that they changed the highly favorable outcome of patients with double NOTCH1/FBXW7 mutations. These results indicate that, for pediatric patients treated according to current protocols, routine screening for PTEN or RAS abnormalities at diagnosis is not warranted to further refine risk stratification.
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Affiliation(s)
- S Jenkinson
- Department of Haematology, UCL Cancer Institute, London, UK
| | - A A Kirkwood
- Cancer Research UK & UCL Cancer Trials Centre, London, UK
| | - N Goulden
- Department of Haematology, Great Ormond Street Hospital, London, UK
| | - A Vora
- Department of Haematology, Sheffield Children's Hospital, Sheffield, UK
| | - D C Linch
- Department of Haematology, UCL Cancer Institute, London, UK
| | - R E Gale
- Department of Haematology, UCL Cancer Institute, London, UK
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19
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Goulden N, Khusnulina A, Davis NJ, Bracewell RM, Bokde AL, McNulty JP, Mullins PG. The salience network is responsible for switching between the default mode network and the central executive network: replication from DCM. Neuroimage 2014; 99:180-90. [PMID: 24862074 DOI: 10.1016/j.neuroimage.2014.05.052] [Citation(s) in RCA: 426] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 05/06/2014] [Accepted: 05/18/2014] [Indexed: 12/20/2022] Open
Abstract
With the advent of new analysis methods in neuroimaging that involve independent component analysis (ICA) and dynamic causal modelling (DCM), investigations have focused on measuring both the activity and connectivity of specific brain networks. In this study we combined DCM with spatial ICA to investigate network switching in the brain. Using time courses determined by ICA in our dynamic causal models, we focused on the dynamics of switching between the default mode network (DMN), the network which is active when the brain is not engaging in a specific task, and the central executive network (CEN), which is active when the brain is engaging in a task requiring attention. Previous work using Granger causality methods has shown that regions of the brain which respond to the degree of subjective salience of a stimulus, the salience network, are responsible for switching between the DMN and the CEN (Sridharan et al., 2008). In this work we apply DCM to ICA time courses representing these networks in resting state data. In order to test the repeatability of our work we applied this to two independent datasets. This work confirms that the salience network drives the switching between default mode and central executive networks and that our novel technique is repeatable.
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20
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Jenkinson S, Koo K, Mansour MR, Goulden N, Vora A, Mitchell C, Wade R, Richards S, Hancock J, Moorman AV, Linch DC, Gale RE. Impact of NOTCH1/FBXW7 mutations on outcome in pediatric T-cell acute lymphoblastic leukemia patients treated on the MRC UKALL 2003 trial. Leukemia 2013; 27:41-7. [PMID: 22814294 DOI: 10.1038/leu.2012.176] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 06/27/2012] [Indexed: 12/24/2022]
Abstract
Activating mutations in the NOTCH1 pathway are frequent in pediatric T-cell acute lymphoblastic leukemia (T-ALL) but their role in refining risk stratification is unclear. We screened 162 pediatric T-ALL patients treated on the MRC UKALL2003 trial for NOTCH1/FBXW7 gene mutations and related genotype to response to therapy and long-term outcome. Overall, 35% were wild-type (WT) for both genes (NOTCH1(WT)FBXW7(WT)), 38% single NOTCH1 mutant (NOTCH1(Single)FBXW7(WT)), 3% just FBXW7 mutant (NOTCH1(WT)FBXW7(MUT)) and 24% either double NOTCH1 mutant (NOTCH1(Double)FBXW7(WT)) or mutant in both genes (NOTCH1(MUT)FBXW7(MUT)), hereafter called as NOTCH1±FBXW7(Double). There was no difference between groups in early response to therapy, but NOTCH1±FBXW7(Double) patients were more likely to be associated with negative minimal residual disease (MRD) post-induction than NOTCH1(WT)FBXW7(WT) patients (71% versus 40%, P=0.004). Outcome improved according to the number of mutations, overall survival at 5 years 82%, 88% and 100% for NOTCH1(WT)FBXW7(WT), NOTCH1(Single)FBXW7(WT) and NOTCH1±FBXW7(Double) patients, respectively (log-rank P for trend=0.005). Although 14 NOTCH1±FBXW7(Double) patients were classified as high risk (slow response and/or MRD positive), only two had disease progression and all remain alive. Patients with double NOTCH1 and/or FBXW7 mutations have a very good outcome and should not be considered for more intensive therapy in first remission, even if slow early responders or MRD positive after induction therapy.
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Affiliation(s)
- S Jenkinson
- Department of Haematology, UCL Cancer Institute, London, UK
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21
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Hiwarkar P, Gaspar HB, Gilmour K, Jagani M, Chiesa R, Bennett-Rees N, Breuer J, Rao K, Cale C, Goulden N, Davies G, Amrolia P, Veys P, Qasim W. Impact of viral reactivations in the era of pre-emptive antiviral drug therapy following allogeneic haematopoietic SCT in paediatric recipients. Bone Marrow Transplant 2012. [PMID: 23178547 DOI: 10.1038/bmt.2012.221] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
While pre-emptive rituximab therapy for EBV has substantially reduced the incidence of post-transplant lymphoproliferative disorder, following allogeneic haematopoietic SCT (HSCT), cytomegalovirus (CMV) and adenovirus (ADV) still contribute to significant morbidity and mortality after HSCT. We therefore aimed to identify high-risk children who could benefit from recent advances in virus-specific immunotherapy, define the impact of viral reactivations on survival and estimate the economic burden of pre-emptive antiviral drug therapy. Between 2005 and 2010, prospective monitoring of 291 paediatric HSCT procedures revealed that reactivation of CMV (16%), ADV (15%) and EBV (11%) was frequent during period of CD4 T-cell lymphopenia (0.15 × 10(9) L(-1); P<0.05). We report significant risk factors for reactivation, most notably the use of serotherapy and development of GVHD (grade II) in the presence of pre-existing infection (ADV) or donor and/or recipient seropositivity (CMV, EBV). Most interestingly, CMV and ADV viraemia were the major independent predictors of mortality (P<0.05). CMV, ADV or EBV viral reactivation caused prolonged hospitalization (P<0.05), accounted for 15% of all mortality and substantially increased the cost of transplantation by ∼£22 500 ($34 000). This provides an economic rationale for targeting high-risk HSCT recipients with interventions such as virus-specific cell therapy.
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Affiliation(s)
- P Hiwarkar
- Molecular Immunology Unit, Institute of Child Health London, UK.
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22
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Bond J, Hough R, Moppett J, Vora A, Mitchell C, Goulden N. 'Stroke-like syndrome' caused by intrathecal methotrexate in patients treated during the UKALL 2003 trial. Leukemia 2012; 27:954-6. [PMID: 23149600 DOI: 10.1038/leu.2012.328] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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23
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Goulden N, McKie S, Thomas EJ, Downey D, Juhasz G, Williams SR, Rowe JB, Deakin JW, Anderson IM, Elliott R. Reversed frontotemporal connectivity during emotional face processing in remitted depression. Biol Psychiatry 2012; 72:604-11. [PMID: 22682158 PMCID: PMC3657140 DOI: 10.1016/j.biopsych.2012.04.031] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 04/30/2012] [Accepted: 04/30/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Vulnerability to relapse persists after remission of an acute episode of major depressive disorder. This has been attributed to abnormal biases in the processing of emotional stimuli in limbic circuits. However, neuroimaging studies have not so far revealed consistent evidence of abnormal responses to emotional stimuli in limbic structures, such as the amygdala, in remitted depression. This suggests the problem might lie in the integrated functioning of emotion processing circuits. METHODS We recruited 22 unmedicated patients in remission from major depressive disorder (rMDD) and 21 age-matched healthy control subjects. Functional magnetic resonance imaging was performed during a face emotion processing task. Dynamic causal modeling was used with Bayesian model selection to determine the most likely brain networks and valence-specific modulation of connectivity in healthy control subjects and rMDD. RESULTS In healthy volunteers, sad faces modulated bi-directional connections between amygdala and orbitofrontal cortex and between fusiform gyrus and orbitofrontal cortex. Happy faces modulated unidirectional connections from fusiform gyrus to orbitofrontal cortex. In rMDD, the opposite pattern was observed, with evidence of happy faces modulating bidirectional frontotemporal connections and sad faces modulating unidirectional fusiform-orbitofrontal connections. CONCLUSIONS Participants with rMDD have abnormal modulation of frontotemporal effective connectivity in response to happy and sad face emotions, despite normal activations within each region. Specifically, processing of mood incongruent happy information was associated with a more richly modulated frontotemporal brain network, whereas mood congruent sad information was associated with less network modulation. This supports a hypothesis of dysfunction within cortico-limbic connections in individuals vulnerable to depression.
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Affiliation(s)
- Nia Goulden
- Neuroscience and Psychiatry Unit, University of Manchester and Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Shane McKie
- Neuroscience and Psychiatry Unit, University of Manchester and Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Emma J. Thomas
- Neuroscience and Psychiatry Unit, University of Manchester and Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Darragh Downey
- Imaging Science, University of Manchester, Manchester, United Kingdom
| | - Gabriella Juhasz
- Neuroscience and Psychiatry Unit, University of Manchester and Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | | | - James B. Rowe
- Department of Clinical Neurosciences, Cambridge University, Cambridge, United Kingdom
| | - J.F. William Deakin
- Neuroscience and Psychiatry Unit, University of Manchester and Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Ian M. Anderson
- Neuroscience and Psychiatry Unit, University of Manchester and Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Rebecca Elliott
- Neuroscience and Psychiatry Unit, University of Manchester and Manchester Academic Health Sciences Centre, Manchester, United Kingdom
- Address correspondence to Rebecca Elliott, Ph. D., Neuroscience and Psychiatry Unit, University of Manchester, Stopford Building, Oxford Road, Manchester, M13 9PT United Kingdom
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Goulden N, Elliott R, Suckling J, Williams SR, Deakin JFW, McKie S. Sample size estimation for comparing parameters using dynamic causal modeling. Brain Connect 2012; 2:80-90. [PMID: 22559836 DOI: 10.1089/brain.2011.0057] [Citation(s) in RCA: 20] [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] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Functional magnetic resonance imaging (fMRI) has proved to be useful for analyzing the effects of illness and pharmacological agents on brain activation. Many fMRI studies now incorporate effective connectivity analyses on data to assess the networks recruited during task performance. The assessment of the sample size that is necessary for carrying out such calculations would be useful if these techniques are to be confidently applied. Here, we present a method of estimating the sample size that is required for a study to have sufficient power. Our approach uses Bayesian Model Selection to find a best fitting model and then uses a bootstrapping technique to provide an estimate of the parameter variance. As illustrative examples, we apply this technique to two different tasks and show that for our data, ~20 volunteers per group is sufficient. Due to variability between task, volunteers, scanner, and acquisition parameters, this would need to be evaluated on individual datasets. This approach will be a useful guide for Dynamic Causal Modeling studies.
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Affiliation(s)
- Nia Goulden
- Neuroscience and Psychiatry Unit, University of Manchester, Manchester, United Kingdom.
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25
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Slatter M, Rao K, Chiesa R, Amrolia P, Nademi Z, Flood T, Abinun M, Cant A, Hambleton S, Goulden N, Davies G, Qasim W, Gaspar H, Gennery A, Veys P. Treosulfan, Fludarabine and Alemtuzumab Conditioning for Hematopoietic Stem Cell Transplantation in Children with Primary Immunodeficiency: UK Experience. Biol Blood Marrow Transplant 2012. [DOI: 10.1016/j.bbmt.2011.12.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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26
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Wootten V, Goulden N, Veys P, Qasim W. A double cure: Omenn syndrome and β thalassaemia successfully treated with mismatched unrelated donor transplantation. Bone Marrow Transplant 2011; 47:589-90. [PMID: 21602897 DOI: 10.1038/bmt.2011.115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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27
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Samarasinghe S, Steward C, Hiwarkar P, Bonney D, Keogh S, Rao K, Amrolia P, Goulden N, Mathew S, Hough R, Wynn R, Veys P. Alemtuzumab-Based Conditioning Protocols for Paediatric Matched Unrelated Donor Transplants for Severe Aplastic Anaemia: An Important Alternative to TBI Containing Regimens. Biol Blood Marrow Transplant 2011. [DOI: 10.1016/j.bbmt.2010.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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28
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Chiesa R, Rao K, Hewitt A, Qasim W, Amrolia P, Goulden N, Veys P. Unrelated Umbilical Cord Blood Transplantation (UCBT) Without Serotherapy In Children Is Associated With Rapid CD4+T-Cell Reconstitution And Recovery Of Anti-Viral Responses. Biol Blood Marrow Transplant 2010. [DOI: 10.1016/j.bbmt.2009.12.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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29
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Slatter M, Rao K, Amrolia P, Flood T, Abinun M, Cant A, Hambleton S, Goulden N, Gennery A, Veys P. UK Experience Of Treosulfan-Based Conditioning Regimens In Children With Primary Immunodeficiency Or Severe Immune Dysregulation. Biol Blood Marrow Transplant 2010. [DOI: 10.1016/j.bbmt.2009.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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30
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James C, Gupta A, Cheng D, Padley S, Goulden N, Skellett S. A boy frightened of going to bed and bumps in the night. West J Med 2009. [DOI: 10.1136/bmj.b2787] [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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31
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Goulden N, McKie S, Suckling J, Elliott R, Deakin JF. Power calculations for effective connectivity analysis and comparison with permutation tesitng. Neuroimage 2009. [DOI: 10.1016/s1053-8119(09)71795-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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32
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Cooper N, Rao K, Goulden N, Webb D, Amrolia P, Veys P. The use of reduced-intensity stem cell transplantation in haemophagocytic lymphohistiocytosis and Langerhans cell histiocytosis. Bone Marrow Transplant 2009; 42 Suppl 2:S47-50. [PMID: 18978744 DOI: 10.1038/bmt.2008.283] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Allogeneic stem cell transplant is curative for haemophagocytic lymphohistiocytosis (HLH) and refractory Langerhans cell histiocytosis (LCH). However, patients frequently have significant pre-transplant morbidity and there is high TRM. Because HLH is caused by immune dysregulation, we surmised that a reduced-intensity conditioned (RIC) regimen might be sufficient for cure, while decreasing the TRM. In 2006, we reported the outcome of 12 patients treated with RIC SCT from a matched family/unrelated or haploidentical donor. Here we discuss the update of these patients, including a total of 25 patients treated with RIC SCT for HLH and three for LCH. Twenty-one of the twenty-five patients with HLH (84%) are alive and well with remission at a median of 36 months from SCT. Mortality included pneumonitis (n=3) and hepatic rupture (n=1). All three patients treated with RIC SCT for LCH remain alive and in remission at a median of 5.1 years from SCT. Seven of twenty-four survivors (one with LCH) have mixed chimerism but remain disease-free. These data are supported by other groups including 100% survival in seven patients with HLH and 78% survival of nine patients with LCH. In summary, RIC compares favourably with conventional SCT with long-term disease control in surviving patients with both HLH and LCL, despite a significant incidence of mixed chimerism.
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Affiliation(s)
- N Cooper
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children NHS Trust, London, UK
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33
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Bonanomi S, Connor P, Webb D, Ancliff P, Amrolia P, Rao K, McCloskey D, Hemmatpour S, Goulden N, Veys P. Erratum: Successful outcome of allo-SCT in high-risk pediatric AML using chemotherapy-only conditioning and post transplant immunotherapy. Bone Marrow Transplant 2008. [DOI: 10.1038/bmt.2008.342] [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: 11/09/2022]
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34
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Krejci O, van der Velden VHJ, Bader P, Kreyenberg H, Goulden N, Hancock J, Schilham MW, Lankester A, Révész T, Klingebiel T, van Dongen JJM. Level of minimal residual disease prior to haematopoietic stem cell transplantation predicts prognosis in paediatric patients with acute lymphoblastic leukaemia: a report of the Pre-BMT MRD Study Group. Bone Marrow Transplant 2003; 32:849-51. [PMID: 14520434 DOI: 10.1038/sj.bmt.1704241] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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35
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Moppett J, van der Velden VHJ, Wijkhuijs AJM, Hancock J, van Dongen JJM, Goulden N. Inhibition affecting RQ-PCR-based assessment of minimal residual disease in acute lymphoblastic leukemia: reversal by addition of bovine serum albumin. Leukemia 2003; 17:268-70. [PMID: 12529693 DOI: 10.1038/sj.leu.2402751] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2002] [Accepted: 07/17/2002] [Indexed: 11/08/2022]
MESH Headings
- Acute Disease
- Animals
- Cattle
- DNA, Neoplasm/genetics
- DNA, Neoplasm/metabolism
- Diagnosis, Differential
- Gene Rearrangement, T-Lymphocyte/genetics
- Genes, Immunoglobulin/genetics
- Genes, T-Cell Receptor/genetics
- Humans
- Leukemia, Lymphoid/diagnosis
- Leukemia, Lymphoid/genetics
- Leukemia, Lymphoid/immunology
- Neoplasm, Residual/diagnosis
- Neoplasm, Residual/genetics
- Neoplasm, Residual/immunology
- Polymerase Chain Reaction/drug effects
- Polymerase Chain Reaction/methods
- Precursor B-Cell Lymphoblastic Leukemia-Lymphoma/diagnosis
- Precursor B-Cell Lymphoblastic Leukemia-Lymphoma/genetics
- Precursor B-Cell Lymphoblastic Leukemia-Lymphoma/immunology
- Reference Standards
- Reproducibility of Results
- Sensitivity and Specificity
- Serum Albumin, Bovine/genetics
- Serum Albumin, Bovine/metabolism
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36
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Marks DI, Bird JM, Vettenranta K, Hunt L, Green A, Cornish JM, Goulden N, Pamphilon DH, Steward CG, Oakhill A. T cell-depleted unrelated donor bone marrow transplantation for acute myeloid leukemia. Biol Blood Marrow Transplant 2001; 6:646-53. [PMID: 11128816 DOI: 10.1016/s1083-8791(00)70031-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [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: 11/22/2022]
Abstract
The outcome for 39 patients with acute myeloid leukemia (AML) in remission who had CAMPATH 1M T cell-depleted unrelated donor bone marrow transplantations (BMTs) is described. Conditioning was mainly with cyclophosphamide (120 mg/kg) and total body irradiation (TBI) (14.4 Gy), but 5 patients received busulfan in place of TBI and 200 mg/kg cyclophosphamide. All patients received cyclosporin, and short-course methotrexate was given to recipients of mismatched grafts. The patient population was predominantly pediatric (median age, 10 years), but one third of the patients was aged 15 years or above. Twenty-five patients were in second complete remission (CR2), and 14 had high-risk CR1 disease (primarily failed remission induction or antecedent myelodysplastic syndrome, often with complex cytogenetic abnormalities). Both recipient and donor were cytomegalovirus seronegative in 15 of 37 cases (38%); 51% of patients were matched for HLA class I and II. Grade II to IV acute graft-versus-host disease (GVHD) occurred in 24% of patients; chronic GVHD occurred in 5 of 31 evaluable patients (16%), 4 extensive and 1 limited. Relapse occurred in 5 cases (13%); 1 of these 5 patients survives, 24 months after a second unrelated donor transplantation. Two of these relapses were associated with secondary graft failure (incidence rate, 5%). All patients engrafted primarily. Severe viral infection was the major transplant-associated complication, with 12 episodes in 9 patients, 5 of them lethal. Twenty-five patients survive at a median follow-up of 44 months (range, 2-102 months), with estimated actuarial overall and disease-free survival rates at 44 months of 61% (SE 8%) and 57% (SE 8%), respectively. Nineteen patients are more than 2 years post-BMT and may be cured. The functional status of long-term survivors is excellent, with 19 of 21 patients who survive 6 months or more in full-time employment or full-time students. These encouraging results suggest that in patients lacking a sibling donor, unrelated donor BMT for AML in remission achieves survival figures as good as or better than those reported on patients with autologous stem cell transplantation, and that T-cell depletion of grafts is associated with a low relapse rate and an excellent functional status. However, only a randomized study comparing unrelated donor BMT and auto-grafting will resolve which of these treatment strategies is better for patients with AML.
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Affiliation(s)
- D I Marks
- Bone Marrow Transplant Unit, Oncology Day Beds, Bristol Children's Hospital, United Bristol Healthcare Trust, UK.
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Fuge R, Bird JM, Fraser A, Hart D, Hunt L, Cornish JM, Goulden N, Oakhill A, Pamphilon DH, Steward CG, Marks DI. The clinical features, risk factors and outcome of thrombotic thrombocytopenic purpura occurring after bone marrow transplantation. Br J Haematol 2001; 113:58-64. [PMID: 11328282 DOI: 10.1046/j.1365-2141.2001.02699.x] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In this study, we retrospectively analysed the clinical features, risk factors and outcome of 22 patients with thrombotic thrombocytopenic purpura (TTP) occurring after allogeneic stem cell transplantation. All but two of these patients received stem cells from unrelated donors (UDs), two-thirds were female, three-quarters were adults and leukaemia was the major reason for transplant. The incidence of TTP was 20 out of 332 patients (6%) with UD transplants and two out of 104 recipients (2%) of matched sibling allografts (P = 0.16). In order to ascertain basic demographic risk factors for the development of TTP, we compared the 22 patients with 434 patients who did not develop TTP. Compared with patients who did not develop TTP, patients with TTP were nearly three times older (P < 0.001) and were more than twice as likely to be female (P = 0.001). Because > 90% of patients were recipients of UD marrow, we then compared the 20 UD-bone marrow transplantation (BMT) patients with 60 randomly selected UD-BMT patients who did not develop TTP. On univariate analysis, age and female gender were again significant risk factors, as was grade II-IV acute graft-versus-host disease (GvHD) (P = 0.002), and there was a trend towards an association with chronic GvHD (P = 0.083). However, after logistic regression analysis, only age and sex remained significant (P < 0.001 and 0.009 respectively). We report an 86% mortality with only three survivors out of 22 patients, and one of these remains thrombocytopenic and red cell transfusion dependent, possibly in part because of graft hypoplasia. Six out of 17 patients responded to plasmapheresis, but the majority of them ultimately succumbed because of TTP, often in association with GvHD or fungal infection.
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Affiliation(s)
- R Fuge
- Bone Marrow Transplant Unit, Bristol Children's Hospital, United Bristol Healthcare Trust, Bristol, UK
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Affiliation(s)
- N Goulden
- University of Bristol and Bristol Children's Hospital, Bristol, UK.
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Baldwin A, Kingman H, Darville M, Foot AB, Grier D, Cornish JM, Goulden N, Oakhill A, Pamphilon DH, Steward CG, Marks DI. Outcome and clinical course of 100 patients with adenovirus infection following bone marrow transplantation. Bone Marrow Transplant 2000; 26:1333-8. [PMID: 11223974 DOI: 10.1038/sj.bmt.1702716] [Citation(s) in RCA: 203] [Impact Index Per Article: 8.5] [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: 11/08/2022]
Abstract
We conducted a retrospective review of the clinical features and outcome of adenovirus infection in 572 consecutive patients transplanted in a single centre over a 10 year period. One hundred patients (17%) had a total of 105 episodes of adenovirus infection diagnosed at a median of 18 days post transplant (range 2-150 days). The incidence was higher in children than adults (21% vs 9%, P < 0.001) and in unrelated donor vs matched sibling donor transplants (26% vs 9%, P < 0.001). Diarrhoea and fever were the most common presenting features. Reflecting these symptoms, the most common site of isolation was the stool. Serotypes 1, 2 and 7 were the most frequently seen (total of 41/68 or 60% of evaluable cases). In six patients (6%) adenovirus infection was the direct cause of death occurring at a median of 72 days post transplant (range 18-365 days). Five of these six patients had pulmonary involvement and four had associated graft-versus-host disease (GVHD). Three further patients were considered to have severe adenoviral disease (total incidence 9%). Isolation of virus from multiple sites correlated with a poor outcome (P < 0.001). Comorbid viral infection was common in this group with 50% of all patients having other viruses isolated (predominantly polyoma virus and cytomegalovirus). We conclude that adenovirus is commonly isolated after bone marrow transplant and is a cause of significant morbidity but was a rare cause of mortality (6/572 = 1%) in our patient group as a whole. The relative infrequency of severe infection will make it difficult for the transplant physician to decide which patients should receive experimental antiviral drugs such as ribavirin and cidofovir or immunomodulatory therapy with donor white cell infusions.
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Affiliation(s)
- A Baldwin
- Bone Marrow Transplant Unit, Bristol, UK
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Grimwade D, Jamal R, Goulden N, Kempski H, Mastrangelo S, Veys P. Salvage of patients with acute promyelocytic leukaemia with residual disease following ABMT performed in second CR using all-trans retinoic acid. Br J Haematol 1998; 103:559-62. [PMID: 9827935 DOI: 10.1046/j.1365-2141.1998.01008.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Detection of residual disease after completion of therapy or following bone marrow transplantation (BMT) in patients with acute promyelocytic leukaemia (APL) predicts relapse and is associated with a poor prognosis. Here we describe the successful treatment of residual disease post-transplant in APL using prolonged all-trans retinoic acid (ATRA) therapy in two children in whom autologous BMT (ABMT) had been performed in second complete remission (CR). ATRA treatment was well tolerated and found to be beneficial despite its prior use as a component of the initial induction protocol. ATRA therapy post-transplant led to molecular remission as determined by fluorescence in situ hybridization (FISH) as well as reverse transcriptase-polymerase chain reaction (RT-PCR) analyses and remission now exceeds 3.5 years in both patients. Overall, this study not only demonstrates that ATRA may successfully salvage APL patients with residual disease post-transplant, but also suggests a potential role for retinoids post-consolidation as a means of eliminating residual disease which could be beneficial even in patients previously exposed to ATRA as a component of the induction protocol.
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Affiliation(s)
- D Grimwade
- Division of Medical and Molecular Genetics, United Medical and Dental Schools of Guy's and St Thomas' Hospitals, London
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Veys PA, Meral A, Hassan A, Goulden N, Webb D, Davies G. Haploidentical related transplants and unrelated donor transplants with T cell addback. Bone Marrow Transplant 1998; 21 Suppl 2:S42-4. [PMID: 9630324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Only 30% of children have a matched family donor (MFD). Alternative donors can be found from volunteer unrelated donor (UD) panels, and almost every child has a haploidentical parental donor (Haplo). The outcome of alternative donor BMT has previously been inferior due to increased graft rejection and GVHD. The recent outcome of 121 consecutive children undergoing MFD, UD, and Haplo BMT between 1994 and 1997 was analysed. [table in text] Preparative regimens for MFD/UD/Haplo BMT respectively included TBI in 30%/36%/11%, chemotherapy only in 59%/64%/89%, Campath 1G or none n 14%/ 0%/0%. The balance of GVHD and rejection was addressed by T-cell depletion (Campath 1M) in 2/71 MFD BMTs, T-cell depletion with addback of 5 x 10(4) T cells/kg on day zero in 33/41 UD BMTs, and T cell depletion of purified mobilised peripheral blood CD34+ cells and bone marrow in 9/9 Haplo BMTs. Stable engraftment was achieved in 68/71, and 35/41 (one patient after 2nd BMT) and 7/9 MFD, UD, and Haplo BMTs respectively. Median follow up, survival, disease free survival and, death rates for MFD/UD/Haplo BMT were 12/12/12 months, 74%/77%/78%, 69%/67%/67%, and 27%/23%/23% respectively. Within a wide range of paediatric diseases the outcome of alternative donor BMT now parallels that of MFD BMT.
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Affiliation(s)
- P A Veys
- Great Ormond Street Hospital for Children NHS Trust, London, UK
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Cornish JM, Pamphilon DH, Potter MN, Steward CG, Goodman S, Green A, Goulden P, Goulden N, Knechtli C, Hale G, Waldmann H, Oakhill A. Unrelated donor bone marrow transplant in childhood ALL. The role of T-cell depletion. Bone Marrow Transplant 1996; 18 Suppl 2:31-5. [PMID: 8932795] [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: 02/03/2023]
Affiliation(s)
- J M Cornish
- Royal Hospital for Sick Children, St. Michael's Hill, Bristol, UK
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Chown SR, Potter MN, Cornish J, Goulden P, Goulden N, Pamphilon D, Steward CG, Oakhill AO. Matched and mismatched unrelated donor bone marrow transplantation for juvenile chronic myeloid leukaemia. Br J Haematol 1996; 93:674-6. [PMID: 8652391 DOI: 10.1046/j.1365-2141.1996.d01-1699.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Juvenile chronic myeloid leukaemia (JCML) is a rare haematological condition of childhood curable only by bone marrow transplantation (BMT). We report our experience using matched and mismatched unrelated donor BMT for JCML in five patients. Although the procedure is hazardous in terms of toxicity and relapse, two patients are alive and disease-free 28 and 49 months post BMT.
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Affiliation(s)
- S R Chown
- Bone Marrow Transplant Unit, Royal Hospital for Sick Children, Bristol
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Chown SR, Goulden N, Cornish JM, Oakhill A, Pamphilon D, Potter MN. The role of plasma exchange for TTP/HUS post-bone marrow transplant. Bone Marrow Transplant 1996; 17:898-9. [PMID: 8733720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Molloy K, Goulden N, Lawler M, Cornish J, Oakhill A, Pamphilon D, Potter M, Steward C, Langlands K, Humphries P, McCann SR. Patterns of hematopoietic chimerism following bone marrow transplantation for childhood acute lymphoblastic leukemia from volunteer unrelated donors. Blood 1996; 87:3027-31. [PMID: 8639926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Hematopoietic chimerism was analyzed in serial bone marrow samples taken from 28 children following T-cell depleted unrelated donor bone marrow transplants (UD BMT) for acute lymphoblastic leukemia (ALL). Chimeric status was determined by polymerase chain reaction (PCR) of simple tandem repeat (STR) sequences (maximal sensitivity, 0.1%). At least two serial samples were examined in 23 patients. Of these, two had evidence of complete donor engraftment at all times and eight showed stable low level mixed chimerism (MC) (<1% recipient hematopoiesis). All 10 of these patients remain in remission with a minimum follow-up of 24 months. By contrast, 13 patients demonstrated a progressive return of recipient hematopoiesis. Five of these relapsed (4 to 9 months post BMT), one died of cytomegalovirus pneumonitis and seven remain in remission with a minimum follow-up of 24 months. Five children were excluded from serial analysis as two serial samples were not collected before either relapse (3) or graft rejection (2). We conclude that as with sibling transplants, ex vivo T depleted UD BMT in children with ALL is associated with a high incidence of MC. Stable donor engraftment and low level MC always correlated with continued remission. However, detection of a progressive return of recipient cells did not universally correlate with relapse, but highlighted those patients at greatest risk. Serial chimerism analysis by PCR of STRs provides a rapid and simple screening technique for the detection of relapse and the identification of patients with progressive MC who might benefit from detailed molecular analysis for minimal residual disease following matched volunteer UD BMT for childhood ALL.
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Affiliation(s)
- K Molloy
- Department of Haematology and Oncology, St James's Hospital, Dublin, Ireland
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Goulden N, Langlands K, Steward C, Knechtli C, Potter M, Oakhill T. PCR of Gene Rearrangements for the Detection of Minimal Residual Disease in Childhood ALL. Methods Mol Med 1996; 6:3-23. [PMID: 21380693 DOI: 10.1385/0-89603-341-4:3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The study of submicroscopic or minimal residual disease (MRD) in childhood acute lymphoblastic leukemia may eventually lead to stratification of therapy on an individual patient basis (reviewed in ref. 1). PCR of immunoglobulin heavy chain (IgH) and T-cell receptor (TCR) gene rearrangements provides widely informative markers (Table 1), which, in the majority of cases, are stable during the disease course (2). Generation of leukemia-specific probes using this technique allows detection of MRD at levels of one leukemic cell in 10,000 to 100,000 normal bone marrow mononuclear cells (BM MNC). Table 1 Primer Systems ( a ) Locus No( b ) Primer sense (ref) No( b ) Primer antisense (ref) [Mg(2+)] Size, bp +B +T- IgH FR3 1 5'-ACACGGC(C/T)(G/C)TGTATTACTGT-3' (2) 3 5'-GTGACCAGGGT(C/T)C C(C/T)TGGCCCCAG-3' (2) 1.5-30 65-155 75% 8% 4 5'-AACTGCAGAGGAGACGGTGACC-3' (3) 15-30 80-170 2 5'-GACCAGGGT(C/T)C C(C/T)TGGCCCCAG-3'( e ) Vδ2-Dδ3 5 5'-CTTGCACCATCAGAGAGAGA-3' (2) 7 5'-GTTTTTGTACAGGTCTCTGT-3' 10-30 100-150 45% 4% 8 5'-AGGGAAATGCACTTTTGCC-3' (2) 15-30 110-170 6 5'-TTTTGTACAGGTCTCTGT-3' ( c ) Vδ1-Jδ1 5'-GCCTTACAGCTAGAAGATTC-3' 5'-GTTCCTTTTCCAAAGATGAG-3' 15-30 80-150 5% 25% VγI-Jγ1/2( d ) 5'-TG(A/C)(C/T)TCTGG(A/G)GTCTATTACTGT-3' 5'-CGATACTTACCTGTGACAAC(C/A)AG-3' 30 80-160 45% 90%( d ) VγII-Jγ-1/2( d ) 5'-AAACAGGACATAGCTACCTACT-3' 5'-CGATACTTACCTGTGACAAACC/AAG-3' 30 80-160 45% 90%( d ) Lead Vγ2-anti Vγ2 5'-GTCATGTCAGCCATTGAGTT-3' 5'-TCTCTCTCTGATGGTGCAAG-3' 15 220 control control ( a ) The primer shown here use a common buffer and generate products that can easily be resolved on 8% PAGE ( b ) Refers to Fig. 1 ( c ) Sequencing primers ( d ) These primers can be used in a multiplex reaction. The VγI primer is a consensus primer and amplifies all members of this group except Vγ7 + B and +T indicate the percentage of patients by lineage expected to show a clonal rearangement at each locus at diagnosis.
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Affiliation(s)
- N Goulden
- Department of Pathology and Microbiology, University of Bristol, UK
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Lawler M, Locasciulli A, Bacigalupo A, Humphries P, Ljungman P, McCann SR, Nolan N, McDermott EW, Reynolds JR, McCann A, Rafferty R, Sweeney P, Carney D, O’Higgins NJ, Duffy MJ, Gardiner C, Reen DJ, O’Connell MA, Kelleher D, Hall N, O’Neill LAJ, Long A, McCarthy JV, Fernandes RS, Cotter TG, Ryan E, Kitching A, MacMathuna P, Mulligan E, Merriman R, Dervan P, Kelly P, Gorey TF, Lennon JR, Crowe J, Bennett MA, Kay EW, Curran B, O’Donoghue DP, Leader M, Croke DT, O’Connor JM, McKelvey-Martin VJ, McKenna PG, O’Riordan JM, Tobin A, O’Mahoney M, Keogh FM, O’Riordan J, McNamara C, McEneaney P, Daly PA, Farrell M, Young S, Gibbons D, McCarthy P, Mulcahy H, Parfrey NA, Sheahan K, Lambkin H, Mothersill C, Chin D, Sheehan K, Kelehan P, Parfrey N, Morrin M, Khan F, Delaney P, Rowan DM, Orminston WJ, Donnellan PP, Khalid A, Kerin M, O’Hanlon DM, Kent P, Given HF, Kennedy SM, McGeoch G, Spurr NK, Barrett J, O’Sullivan G, Collins JK, Willcocks T, Kennedy S, Dolan J, Gallagher W, McDermott E, O’Higgins N, Hagan R, McManus R, Ormiston W, Daly P, Sheils O, McDermott M, O’Briain DS, Maher D, Costello P, Flanagan F, Stack J, Ennis J, Grimes H, Yanni A, Harrison M, Lowry WS, Russell SEH, Atkinson RJ, White P, Hickey I, Bell DW, Biggart D, Doyle J, Staunton MJ, Gaffney EF, Dervan PA, McCabe MM, Fennelly JJ, Carney DN, O’Reilly M, McMahon JN, Moriarty M, Hurson B, O’Neill AJ, Magee H, O’Loughlin J, Dervan PA, Cremin P, Orminston W, McCarthy J, Redmond P, Duggan S, Rea S, Bouchier-Hayes D, O’Donnell J, Duggan C, Crown J, Bermingham D, Nugent A, Fleming C, Crosby P, Wolff S, McCarthy D, Walsh CB, Cassidy M, Husain S, Kay E, Thornhilll M, Whelan D, Barry D, Turner M, Prenderville W, Murphy F, Prendiville W, Gibson G, O’Grady T, Carmody M, Donohoe J, Walshe J, Murphy GM, O’Donoghue J, Kerin K, Ahern S, Molloy K, Goulden N, Pamphilon DH, O’Connell M, Power C, Leroux A, Perricaudet M, Walls D, Britton F, Brennan L, Barnett YA, Madden B, Wakelin LPG, Loughrey HC, Corley P, Redmond HP, Watson RWG, Keogh I, O’Hanlon D, Walsh S, Callaghan J, McNamara M, Benedict-Smith A, Barnes C, Neylon D, Fenton M, Searcey M, Topham CM, Wakelin LG, Howarth NM, Purohit A, Reed MJ, Potter BVL, Hatton WJ, McKerr G, Harvey D, Carson J, Hannigan BM, McCarthy PJ, McClean S, Hill BT, Costelloe C, Denny WA, Fingleton B, McDonnell S, Butler M, Corbally N, Dervan PA, Stephens JF, Martin G, McGirl A, Lawlor E, Gardiner N, Lynch S, Arce MD, O’Brien F, Duggan A, O’Herlihy S, Shanahan F, O’Keeffe G, McCann S, Sweeney K, Neill AO, Pamphilon D, Sheridan M, Reid I, Seymour CB, Walshe T, Hennessy TP, O’Mahony A, O’Connell’ J, Lawlor C, Nolan S, Morrisey D, Pedlow PJ, Walsh M, Lowry SW, McAleer JJA, McKeown SR, Afrasiabi M, Lappin TRJ, Joiner B, Hirst KV, Hirst DG, Sweeney E, VanderSpek J, Murphy J, Foss F. Irish Association for Cancer Research. Ir J Med Sci 1995. [DOI: 10.1007/bf02967834] [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: 11/28/2022]
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Goulden N. Manual of pediatric hematology and oncology P. Lanzkowsky. 2nd edn. Churchill-Livingstone, Edinburgh. 1994. No. of pages: 704. Price: £80 (Hardback). ISBN: 044 308 9698. Hematol Oncol 1995. [DOI: 10.1002/hon.2900130408] [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: 11/06/2022]
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Goulden N, Langlands K, Steward C, Katz F, Potter M, Chessells J, Oakhill A. PCR assessment of bone marrow status in 'isolated' extramedullary relapse of childhood B-precursor acute lymphoblastic leukaemia. Br J Haematol 1994; 87:282-5. [PMID: 7947268 DOI: 10.1111/j.1365-2141.1994.tb04910.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Approximately one-third of first relapses of childhood ALL occur at an extramedullary site without morphological evidence of bone marrow disease. However, the high incidence of subsequent medullary relapse in these cases strongly suggests that leukaemia is present at submicroscopic levels at the time of 'isolated' relapse. PCR analysis of immunoglobulin heavy chain (IgH) and T-cell receptor (TCR) gene rearrangements now allows detection of leukaemia at levels as low as 0.001%. We have therefore used this technique to reassess bone marrow status at morphologically isolated relapse in 13 children with B-lineage ALL (11 with off-treatment relapses, two on treatment). In 12 of these 13 patients marrow disease was detectable by PCR at the time of this relapse--in all cases at levels below the threshold of light microscopy. Where relapse occurred off-therapy this indicated re-emergence of disease. since MRD has never been detected by PCR at this stage in patients remaining in long-term remission. In both patients who relapsed on-therapy the level of MRD at the time of relapse represented an increase on that seen in their previous marrow sample. We conclude that re-emerging bone marrow disease can be detected in most cases of 'isolated' relapse when investigated by this highly sensitive technique. Our findings at a molecular level confirm a long-held clinical suspicion and indicate that full systemic re-induction as well as local therapy is obligatory for these children.
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Affiliation(s)
- N Goulden
- Department of Paediatric Haematology/Oncology, Royal Hospital for Sick Children, Bristol
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50
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Vestey JP, Turner M, Biddlestone L, McLaren K, Goulden N, Hunter JA. Disseminated cutaneous granulomatous eruptions associated with myelodysplastic syndrome and acute myeloid leukaemia. Clin Exp Dermatol 1993; 18:559-63. [PMID: 8252798 DOI: 10.1111/j.1365-2230.1993.tb01031.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Two elderly male patients presented with similar, widespread, papular, granulomatous eruptions and developed myelodysplastic syndromes. The first showed histological features of diffuse granuloma annulare and had mild hypergammaglobulinaemia, slightly abnormal liver function and a leucoerythroblastic anaemia. He developed acute myeloid leukaemia (AML) secondary to a background myelodysplastic syndrome and was treated with combination chemotherapy during which his eruption settled; his AML and his skin are in remission 1 year later. The second developed a myelodysplastic syndrome and a similar rash with histological features of papular cutaneous sarcoidosis but no systemic abnormalities apart from mild hypergammaglobulinaemia, cutaneous anergy to multiple recall antigens and activation of circulating monocytes. He has remained well but his rash and myelodysplastic syndrome have persisted. These cases are interesting because of the striking similarity of their granulomatous eruptions and their associated haematological abnormalities. Patients with such disseminated, granulomatous cutaneous infiltrations should be investigated to exclude associated haematological abnormalities if there is any abnormality of their peripheral blood picture.
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Affiliation(s)
- J P Vestey
- University Department of Dermatology, Royal Infirmary of Edinburgh, Scotland
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