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Shah S, Raut S, Conyers R, Ahmed S. 111 The Systemic Effects of Intra-Articular Steroid Injections- Should COVID-19 Change Our Practice? Br J Surg 2021. [DOI: 10.1093/bjs/znab259.969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Aim
The COVID-19 pandemic prompted us to review and often suspend services, while patients continue to suffer with painful musculoskeletal conditions. The diagnostic and therapeutic value of intra-articular corticosteroid injections (IACSI) cannot be denied. Current BOA guidelines advise giving the lowest effective dose for inflammatory arthritis and limit use in osteoarthritis to patients with high levels of pain and disability. We aimed to evaluate the literature pertaining to the use of IACSI and the potential systemic immunosuppressive effects.
Method
We searched Medline, using the terms “systemic effects of intra-articular steroid” and “clinical course of Coronavirus infection in patients with steroid use”, between 1997 and 2020.
Results
No studies specifically looked at the systemic effects of intra-articular steroids in the presence of COVID-19 infection; however, four studies were identified which concluded that intra-articular steroid injections resulted in sufficient systemic absorption to cause suppression of the hypothalamic-pituitary-adrenal axis and endogenous cortisol production. These effects are dose dependent and are more common in patients with inflammatory joint diseases. A further four RCT’s, including one systematic review, showed that suppressed cortisol concentration was associated with a significant increase in mortality.
Conclusions
There is a lack of evidence in relation to the use of intra-articular steroids in COVID-19. However, evidence suggests that intra-articular steroids can result in systemic absorption and suppression of endogenous cortisol production thus increasing the potential risk of complications of COVID-19. We therefore support cautious use of low dose steroid injections in patients with inflammatory arthritis, where no alternative treatment is available.
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Affiliation(s)
- S Shah
- Department of Trauma and Orthopaedics, Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, United Kingdom
| | - S Raut
- Department of Trauma and Orthopaedics, Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, United Kingdom
| | - R Conyers
- Department of Trauma and Orthopaedics, Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, United Kingdom
| | - S Ahmed
- Department of Trauma and Orthopaedics, Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, United Kingdom
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Foulkes S, Costello B, Howden E, Janssens K, Dillon H, Toro C, Fraser S, Daly R, Elliott D, Conyers R, La Gerche A. Exercise cardiac MRI unmasks cardiac dysfunction in childhood and adolescent cancer survivors with reduced cardiopulmonary fitness. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Young cancer survivors are at increased risk of impaired cardiopulmonary fitness (VO2peak) and heart failure. Assessment of exercise cardiac reserve may reveal sub-clinical abnormalities that better explain impairments in fitness and long term heart failure risk.
Purpose
To investigate the presence of impaired VO2peak in pediatric cancer survivors with increased risk of heart failure, and to assess its relationship with resting cardiac function and cardiac reserve
Methods
Twenty pediatric cancer survivors (aged 8–24 years) treated with anthracycline chemotherapy underwent cardiopulmonary exercise testing to quantify VO2peak, with a value <85% of predicted defined as impaired VO2peak. Resting cardiac function was assessed using 3-dimensional echocardiography, with cardiac reserve quantified from resting and peak exercise heart rate (HR), stroke volume index (SVi) and cardiac index (CI) using exercise cardiac magnetic resonance imaging.
Results
12 of 20 survivors (60%) had impaired VO2peak (97±14% vs. 70±16% of age and gender predicted). There were no differences in echocardiographic or CMR measurements of resting cardiac function between survivors with normal or impaired VO2peak. However, those with reduced VO2peak had diminished cardiac reserve, with a lesser increase in CI (Fig. 1A) and SVi (Fig. 1B) during exercise (Interaction P=0.001 for both), whilst the HR response was similar (Fig. 1C; P=0.71).
Conclusions
Resting measures of cardiac function are insensitive to significant cardiac dysfunction amongst pediatric cancer survivors with reduced VO2peak. Measures of cardiopulmonary fitness and cardiac reserve may aid in early identification of survivors with heightened risk of long-term heart failure.
Figure 1
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): National Heart Foundation
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Affiliation(s)
- S Foulkes
- Baker IDI Heart and Diabetes Institute, Sports Cardiology, Melbourne, Australia
| | - B Costello
- Baker IDI Heart and Diabetes Institute, Sports Cardiology, Melbourne, Australia
| | - E.J Howden
- Baker IDI Heart and Diabetes Institute, Sports Cardiology, Melbourne, Australia
| | - K Janssens
- Baker IDI Heart and Diabetes Institute, Sports Cardiology, Melbourne, Australia
| | - H Dillon
- Deakin University, Institute of Physical Activity and Nutrition, Melbourne, Australia
| | - C Toro
- Royal Children's Hospital, Children's Cancer Centre, Melbourne, Australia
| | - S.F Fraser
- Deakin University, Institute of Physical Activity and Nutrition, Melbourne, Australia
| | - R.M Daly
- Deakin University, Institute of Physical Activity and Nutrition, Melbourne, Australia
| | - D.A Elliott
- Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Australia
| | - R Conyers
- Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Australia
| | - A La Gerche
- Baker IDI Heart and Diabetes Institute, Sports Cardiology, Melbourne, Australia
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Wong A, Glogolia M, Lange PW, Dale S, Chappell M, Soosay Raj T, Hanna D, Devaraja L, Williams C, Williamson J, Conyers R. A nurse-led paediatric oncology fast-track clinic proves a successful ambulatory intervention for patients. Support Care Cancer 2020; 28:4395-4403. [PMID: 31919665 DOI: 10.1007/s00520-019-05250-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 12/16/2019] [Indexed: 11/25/2022]
Abstract
AIM To assess the impact of a pilot nurse-led paediatric oncology fast-track clinic (OFTC) for complications and side effects following chemotherapy within a paediatric tertiary hospital. METHODS Prospective clinical data from the first 100 patients seen in the OFTC were compared with retrospective data of oncology patient presentations to the emergency department (ED) (over a 1-year period, n = 196) who would have been eligible for review in the OFTC. Parent and patient satisfaction of clinical care were also assessed via surveys pre- and post-OFTC implementation. RESULTS Analysis which achieved statistical difference was a reduction in the number of blood tubes taken in OFTC (average 1.9 for those discharged from clinic, 2.9 for those admitted from clinic) in comparison to those seen in the ED (average 3.2) (p = 0.0027). The average number of interventions per patient seen in the ED were 2.1 (standard deviation 1.64) compared with 1.7 (standard deviation 1.55) interventions per patient seen in the OFTC, and who were not admitted following review. This result approached statistical significance with p = 0.0963. Other results which did not meet statistical significance included a reduction in treatment times, hospital admissions and medical oncology reviews. CONCLUSION Our pilot study implementing an OFTC for the triage and assessment of chemotherapy-related complications has proven successful from an operational and consumer perspective. The clinic improved care by ensuring expedited review, more streamlined interventions, and less overall hospital admissions. The improvements in efficiency were also mirrored by increased parent and patient satisfaction.
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Affiliation(s)
- A Wong
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - M Glogolia
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - P W Lange
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - S Dale
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - M Chappell
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - T Soosay Raj
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - D Hanna
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - L Devaraja
- Department of Paediatrics, Melbourne University, Melbourne, Australia
| | - C Williams
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia.,The Paediatric Integrated Cancer Service (PICS), Melbourne, Australia
| | - J Williamson
- The Paediatric Integrated Cancer Service (PICS), Melbourne, Australia
| | - R Conyers
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia. .,Department of Paediatrics, Melbourne University, Melbourne, Australia. .,Murdoch Children's Research Institute, Melbourne, Australia.
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Foulkes S, Costello B, Howden E, Elliott D, Conyers R, La Gerche A. Exercise Cardiac MRI Unmasks Cardiac Dysfunction in Childhood and Adolescent Cancer Survivors with Reduced Cardiopulmonary Fitness. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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White VM, Skaczkowski G, Pinkerton R, Coory M, Osborn M, Bibby H, Nicholls W, Orme LM, Conyers R, Phillips MB, Harrup R, Walker R, Thompson K, Anazodo A. Clinical management of Australian adolescents and young adults with acute lymphoblastic and myeloid leukemias: A national population-based study. Pediatr Blood Cancer 2018; 65:e27349. [PMID: 30039912 DOI: 10.1002/pbc.27349] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/23/2018] [Accepted: 06/10/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND While several studies have examined the treatment of adolescents and young adults (AYAs) with acute lymphoblastic leukemia (ALL), studies of acute myeloid leukemia (AML) are rare. Using national data for Australia, we describe (i) the number and type of treatment centers caring for AYAs, (ii) induction/first-line treatments, and (iii) survival outcomes. PROCEDURE National population-based study assessing treatment of 15- to 24-year-olds diagnosed with ALL or AML between 2007 and 2012. Treatment details were abstracted from hospital medical records. Treatment centers were classified as pediatric or adult (adult AYA-focused or other adult; and by AYA volume [high/low]). Cox proportional hazard regression analyses examined associations between treatment and overall, event-free, and relapse-free survival outcomes. RESULTS Forty-seven hospitals delivered induction therapy to 351 patients (181 ALL and 170 AML), with 74 (21%) treated at pediatric centers; 70% of hospitals treated less than two AYA leukemia patients per year. Regardless of treatment center, 82% of ALL patients were on pediatric protocols. For AML, pediatric protocols were not used in adult centers, with adult centers using a non-COG 7+3-type induction protocol (51%, where COG is Cooperative Oncology Group) or an ICE-type protocol (39%, where ICE is idarubicin, cytarabine, etoposide). Exploratory analyses suggested that for both ALL and AML, AYAs selected for adult protocols have worse overall, event-free, and relapse-free survival outcomes. CONCLUSIONS Pediatric protocols were commonly used for ALL patients regardless of where they are treated, indicating rapid assimilation of recent evidence by Australian hematologists. For AML, pediatric protocols were only used at pediatric centers. Further investigation is warranted to determine the optimal treatment approach for AYA AML patients.
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Affiliation(s)
- V M White
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia.,School of Psychology, Deakin University, Burwood, Victoria, Australia
| | - G Skaczkowski
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia.,School of Psychology and Public Health, La Trobe University, Bundoora, Victoria, Australia.,Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - R Pinkerton
- Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - M Coory
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - M Osborn
- Royal Adelaide Hospital, South Australia, Adelaide, Australia
| | - H Bibby
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - W Nicholls
- Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - L M Orme
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - R Conyers
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - M B Phillips
- Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - R Harrup
- Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - R Walker
- Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - K Thompson
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A Anazodo
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia.,Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia
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White VM, Bibby H, Green M, Anazodo A, Nicholls W, Pinkerton R, Phillips M, Harrup R, Osborn M, Orme LM, Conyers R, Thompson K, Coory M. Inconsistencies and time delays in site-specific research approvals hinder collaborative clinical research in Australia. Intern Med J 2016; 46:1023-9. [DOI: 10.1111/imj.13191] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 07/05/2016] [Accepted: 07/05/2016] [Indexed: 11/30/2022]
Affiliation(s)
- V. M. White
- Cancer Council Victoria; Melbourne Victoria Australia
| | - H. Bibby
- Cancer Council Victoria; Melbourne Victoria Australia
| | - M. Green
- Murdoch Childrens Research Institute; Melbourne Victoria Australia
| | - A. Anazodo
- Sydney Children's Hospital; Sydney New South Wales Australia
- Prince of Wales Hospital; Sydney New South Wales Australia
| | - W. Nicholls
- Children's Health Queensland; Brisbane Queensland Australia
| | - R. Pinkerton
- Children's Health Queensland; Brisbane Queensland Australia
| | - M. Phillips
- Princess Margaret Hospital for Children; Perth Western Australia Australia
| | - R. Harrup
- Royal Hobart Hospital; Hobart Tasmania Australia
| | - M. Osborn
- Royal Adelaide Hospital; Adelaide South Australia Australia
| | - L. M. Orme
- Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - R. Conyers
- Royal Children's Hospital; Melbourne Victoria Australia
| | - K. Thompson
- Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - M. Coory
- Murdoch Childrens Research Institute; Melbourne Victoria Australia
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Murnane A, Gough K, Thompson K, Holland L, Conyers R. Erratum to: Adolescents and young adult cancer survivors: exercise habits, quality of life and physical activity preferences. Support Care Cancer 2015; 23:511. [DOI: 10.1007/s00520-014-2527-2] [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: 10/24/2022]
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Murnane A, Gough K, Thompson K, Holland L, Conyers R. Adolescents and young adult cancer survivors: exercise habits, quality of life and physical activity preferences. Support Care Cancer 2014; 23:501-10. [PMID: 25294658 DOI: 10.1007/s00520-014-2446-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 09/14/2014] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Given the decades of survivorship for adolescent and young adult (AYA) cancer survivors, it is important to promote behaviours that enhance physical and mental well-being and quality of life (QoL). The purpose of this study was to explore the exercise programming preferences and information needs of AYA survivors and to examine the impact of a cancer diagnosis on physical activity behavior and QoL. METHODS Participants aged 15-25 years at time of diagnosis and referred to a specialist AYA cancer service between January 2008 and February 2012 were recruited. Eligible participants were mailed a self-administered questionnaire assessing demographic and disease-related information, physical activity levels over time and exercise information preferences. QoL was measured using the Assessment of Quality of Life-6D (AQoL-6D). RESULTS Seventy-four (response rate 52 %) participants completed the questionnaire. The mean age was 23 years with 54 % female, with prevalent diagnoses included hematological malignancy (45 %) and sarcoma (24 %). Results indicated a significant reduction in the average minutes of physical activity post diagnosis (p =< 0.001) and during treatment (p = < 0.001). AYA who met public health physical activity guidelines (n = 36) at questionnaire completion had significantly higher QoL than those not meeting the guidelines (n = 38) (median (Mdn) = 0.87, interquartile range (IQR) = 0.73 to 0.98 and Mdn = 0.81, IQR = 0.57 to 0.93, respectively; p = 0.034). Most participants wanted exercise information at some point after diagnosis (85 %) but many did not receive any information (45 %). CONCLUSIONS Findings suggest that AYA with cancer experience a significant impact on physical activity levels and QoL. Moreover, survivors experience considerable difficulty returning to premorbid levels of activity. Our study suggests that interventions promoting physical activity and healthy lifestyle behaviours would be well accepted within this population and may be essential to improve their long-term health and QoL during survivorship.
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Affiliation(s)
- A Murnane
- ONTrac at Peter Mac Victorian Adolescent and Young Adult Cancer Service Peter MacCallum Cancer Centre, Locked Bag 1 A'Beckett St, Melbourne, VIC, 8006, Australia,
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Rosenfeldt FL, Munsch C, Langley L, Conyers R, Williams JF. Enhanced myocardial metabolism improves recovery after cardiac surgery and transplantation. Clin Exp Pharmacol Physiol 1991; 18:121-2. [PMID: 2022075 DOI: 10.1111/j.1440-1681.1991.tb01420.x] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- F L Rosenfeldt
- Baker Medical Research Institute, Prahran, Victoria, Australia
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