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Sawadogo W, Adera T, Burch JB, Alattar M, Perera R, Howard VJ. Sleep duration and all-cause mortality among stroke survivors. J Stroke Cerebrovasc Dis 2024; 33:107615. [PMID: 38307468 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Post stroke sleep duration could increase the risk of death. This study tested the hypothesis that inadequate sleep duration is associated with increased mortality among stroke survivors. METHODS The REasons for Geographic And Racial Differences in Stroke (REGARDS), a national population-based longitudinal study, was the data source. Sleep duration was ascertained between 2013 and 2016 among stroke survivors who were subsequently followed up until death or censored on December 31, 2022. Sleep duration was estimated as the difference between wake-up time and bedtime to which was subtracted the time spent in bed without sleep. Cox proportional hazards regression models were employed to investigate the association between sleep duration and all-cause mortality adjusting for demographic factors, socioeconomic factors, behavioral factors, and co-morbidities. RESULTS A total of 468 non-Hispanic Black and White stroke survivors were included in this analysis. The mean age was 76.3 years, 52.6% were females and 56.0% were non-Hispanic White individuals. The distribution of short (≤6 h), adequate (7.0-8.9 h), and long sleep (≥9 h) was 30.3%, 44.7%, and 25%, respectively. Over a mean follow-up of 5.0 years, 190 (40.6%) deaths occurred. Compared to stroke survivors with adequate sleep (7.0-8.9 h), stroke survivors with long sleep (≥9 h) were at increased risk of all-cause mortality (HR=1.46, 95% CI=1.01, 2.12). However, short sleep (≤6 h) was not significantly associated with an increased risk of all-cause mortality (HR=1.31, 95% CI=0.90, 1.91). Subgroup analyses indicated higher risk in the age <75 years, females, non-Hispanic Black individuals, and those living in the Stroke Belt region, but those differences were not statistically significant. CONCLUSION In this study of stroke survivors, 9 hours or more of sleep per day was associated with an increased risk of all-cause mortality. This finding suggests that excessive sleep duration may be a warning sign of poor life expectancy in stroke survivors.
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Affiliation(s)
- Wendemi Sawadogo
- Department of Public Health, College of Human and Health Services, Southern Connecticut State University, New Haven, CT, United States; Department of Epidemiology, School of Population Health, Virginia Commonwealth University, Richmond, VA, United States.
| | - Tilahun Adera
- Department of Epidemiology, School of Population Health, Virginia Commonwealth University, Richmond, VA, United States
| | - James B Burch
- Department of Epidemiology, School of Population Health, Virginia Commonwealth University, Richmond, VA, United States
| | - Maha Alattar
- Division of Adult Neurology, Sleep Medicine, Vascular Neurology, Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Robert Perera
- Department of Biostatistics, School of Population Health, Virginia Commonwealth University, Richmond, VA, United States
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
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van der Veen SM, Perera R, Fino PC, Franke LM, Agyemang AA, Skop K, Wilde EA, Sponheim SR, Stamenkovic A, Thomas JS, Walker WC. Sensory functions and their relation to balance metrics: a secondary analysis of the LIMBIC-CENC multicenter cohort. Front Neurol 2023; 14:1241545. [PMID: 37780699 PMCID: PMC10538567 DOI: 10.3389/fneur.2023.1241545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/16/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Among patients with traumatic brain injury (TBI), balance problems often persist alongside hearing and vision impairments that lead to poorer outcomes of functional independence. As such, the ability to regain premorbid independent gait may be dictated by the level of sensory acuity or processing decrements that are shown following TBI assessment. This study explores the relationships between standardized sensory acuity and processing outcomes to postural balance and gait speed. Methods Secondary analysis was performed on the Long-Term Impact of Military- Relevant Brain Injury Consortium Chronic Effects of Neurotrauma Consortium LIMBIC (CENC) data set. Separate regression analyses were carried out for each of the balance assessments (via Computerized Dynamic Posturography, CDP) and walking speed. Discussion TBI frequency was significantly related to the majority of single CDP outcomes (i.e., Conditions 2-6), while various sensory processing outcomes had task-specific influences. Hearing impairments and auditory processing decrements presented with lower CDP scores (CDP Conditions 3,5,6, and 1-3 respectively), whereas greater visual processing scores were associated with better CDP scores for Conditions 2,5, and 6. In sum, patients with TBI had similar scores on static balance tests compared to non-TBI, but when the balance task got more difficult patients with TBI scored worse on the balance tests. Additionally, stronger associations with sensory processing than sensory acuity measures may indicate that patients with TBI have increased fall risk.
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Affiliation(s)
- Susanne M. van der Veen
- Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA, United States
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Robert Perera
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, United States
| | - Peter C. Fino
- Department of Health and Kinesiology, University of Utah, Salt Lake City, UT, United States
| | - Laura Manning Franke
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Amma A. Agyemang
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Karen Skop
- Department of Physical Medicine and Rehabilitation Services, James A. Haley Veterans’ Hospital, Tampa, FL, United States
| | - Elisabeth A. Wilde
- Department of Physical Medicine and Rehabilitation, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Baylor College of Medicine, Houston, TX, United States
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Scot R. Sponheim
- Minneapolis VA Health Care System, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, United States
| | - Alexander Stamenkovic
- Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA, United States
| | - James S. Thomas
- Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA, United States
| | - William C. Walker
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
- Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, United States
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Sawadogo W, Adera T, Alattar M, Perera R, Burch JB. Association Between Insomnia Symptoms and Trajectory With the Risk of Stroke in the Health and Retirement Study. Neurology 2023; 101:e475-e488. [PMID: 37286360 PMCID: PMC10401688 DOI: 10.1212/wnl.0000000000207449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/10/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Insomnia is a common condition affecting more than a third of the US population. However, the link between insomnia symptoms and stroke is understudied and the underlying mechanism remains unclear. This study aimed to investigate the relationship between insomnia symptoms and the incidence of stroke. METHODS The Health and Retirement Study, a survey of Americans older than 50 years and their spouses, from 2002 to 2020 was used as the data source. Only those who were stroke-free at baseline were included in this study. The exposure variable was insomnia symptoms and was derived from self-reported sleep-related factors including difficulty initiating sleep, difficulty maintaining sleep, waking up too early, and nonrestorative sleep. Repeated-measures latent class analysis was used to identify insomnia trajectories over time. To investigate the relationship between insomnia symptoms and stroke events reported during the follow-up period, Cox proportional hazards regression models were used. Mediation analyses of comorbidities were performed using causal mediation within a counterfactual framework. RESULTS A total of 31,126 participants were included with a mean follow-up of 9 years. The mean age was 61 years (SD = 11.1) and 57% were females. Insomnia symptom trajectories remained constant over time. Compared with those with no insomnia symptoms, an increased risk of stroke was observed for those with insomnia symptom scores ranging from 1 to 4 and 5 to 8 (hazard ratio (HR) = 1.16, 95% confidence interval (CI) 1.02-1.33) and (HR = 1.51, 95% CI 1.29-1.77), respectively, indicating a dose-response relationship. The association was stronger in participants younger than 50 years (HR = 3.84, 95% CI 1.50-9.85) than in those aged 50 years and older (HR = 1.38, 95% CI 1.18-1.62), comparing those with insomnia symptoms ranging from 5 to 8 with those with no insomnia symptoms. This association was mediated by diabetes, hypertension, heart disease, and depression. DISCUSSION Insomnia symptoms were associated with an increased risk of stroke, especially in adults younger than 50 years, and the risk was mediated by certain comorbidities. Increased awareness and management of insomnia symptoms may contribute to the prevention of stroke occurrence.
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Affiliation(s)
- Wendemi Sawadogo
- From the Division of Epidemiology (W.S., T.A., J.B.B.), Department of Family Medicine and Population Health, and Division of Adult Neurology (M.A.), Sleep Medicine, Vascular Neurology, Department of Neurology; and Department of Biostatistics (R.P.), Virginia Commonwealth University, School of Medicine, Richmond.
| | - Tilahun Adera
- From the Division of Epidemiology (W.S., T.A., J.B.B.), Department of Family Medicine and Population Health, and Division of Adult Neurology (M.A.), Sleep Medicine, Vascular Neurology, Department of Neurology; and Department of Biostatistics (R.P.), Virginia Commonwealth University, School of Medicine, Richmond
| | - Maha Alattar
- From the Division of Epidemiology (W.S., T.A., J.B.B.), Department of Family Medicine and Population Health, and Division of Adult Neurology (M.A.), Sleep Medicine, Vascular Neurology, Department of Neurology; and Department of Biostatistics (R.P.), Virginia Commonwealth University, School of Medicine, Richmond
| | - Robert Perera
- From the Division of Epidemiology (W.S., T.A., J.B.B.), Department of Family Medicine and Population Health, and Division of Adult Neurology (M.A.), Sleep Medicine, Vascular Neurology, Department of Neurology; and Department of Biostatistics (R.P.), Virginia Commonwealth University, School of Medicine, Richmond
| | - James B Burch
- From the Division of Epidemiology (W.S., T.A., J.B.B.), Department of Family Medicine and Population Health, and Division of Adult Neurology (M.A.), Sleep Medicine, Vascular Neurology, Department of Neurology; and Department of Biostatistics (R.P.), Virginia Commonwealth University, School of Medicine, Richmond
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Covas Moschovas M, Jaber A, Perera R, Sandri M, Rogers T, Morales K, Ortiz C, Patel V. Simultaneous hernia repair in robotic-assisted radical prostatectomy is safe with low rates of mesh complications. EUR UROL SUPPL 2022. [DOI: 10.1016/s2666-1683(22)02258-3] [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: 11/05/2022] Open
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Mejia AJ, Jimenez L, Dutra HLC, Perera R, McGraw EA. Attempts to use breeding approaches in Aedes aegypti to create lines with distinct and stable relative Wolbachia densities. Heredity (Edinb) 2022; 129:215-224. [PMID: 35869302 PMCID: PMC9519544 DOI: 10.1038/s41437-022-00553-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 01/16/2023] Open
Abstract
Wolbachia is an insect endosymbiont being used for biological control in the mosquito Aedes aegypti because it causes cytoplasmic incompatibility (CI) and limits viral replication of dengue, chikungunya, and Zika viruses. While the genetic mechanism of pathogen blocking (PB) is not fully understood, the strength of both CI and PB are positively correlated with Wolbachia densities in the host. Wolbachia densities are determined by a combination of Wolbachia strain and insect genotype, as well as interactions with the environment. We employed both artificial selection and inbreeding with the goal of creating lines of Ae. aegypti with heritable and distinct Wolbachia densities so that we might better dissect the mechanism underlying PB. We were unable to shift the mean relative Wolbachia density in Ae. aegypti lines by either strategy, with relative densities instead tending to cycle over a narrow range. In lieu of this, we used Wolbachia densities in mosquito legs as predictors of relative densities in the remaining individual's carcass. Because we worked with outbred mosquitoes, our findings indicate either a lack of genetic variation in the mosquito for controlling relative density, natural selection against extreme densities, or a predominance of environmental factors affecting densities. Our study reveals that there are moderating forces acting on relative Wolbachia densities that may help to stabilize density phenotypes post field release. We also show a means to accurately bin vector carcasses into high and low categories for non-DNA omics-based studies of Wolbachia-mediated traits.
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Affiliation(s)
- A. J. Mejia
- grid.29857.310000 0001 2097 4281Center for Infectious Disease Dynamics & Department of Entomology, The Pennsylvania State University, University Park, PA 16802 USA
| | - L. Jimenez
- grid.1002.30000 0004 1936 7857School of Life Sciences, Monash University, Clayton, Vic 3800 Australia
| | - H. L. C. Dutra
- grid.29857.310000 0001 2097 4281Center for Infectious Disease Dynamics & Biology, The Pennsylvania State University, University Park, PA 16802 USA
| | - R. Perera
- grid.47894.360000 0004 1936 8083Center for Vector-borne Infectious Diseases and Center for Metabolism of Infectious Diseases, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO USA
| | - E. A. McGraw
- grid.29857.310000 0001 2097 4281Center for Infectious Disease Dynamics & Biology, The Pennsylvania State University, University Park, PA 16802 USA
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Roy S, Min A, Khan O, Perera R, Jovin IS. Phosphodiesterase 5 Inhibitors and the Risk of Nephropathy and Long-Term Outcomes After Coronary Angiography and Percutaneous Coronary Intervention. Cardiovascular Revascularization Medicine 2022. [DOI: 10.1016/j.carrev.2022.06.176] [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: 11/26/2022]
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Coorey NJ, Kensitt L, Davies J, Keller E, Sheel M, Chani K, Barry S, Boyd R, Denholm J, Watts K, Fox G, Lowbridge C, Perera R, Waring J, Marais B, Viney K. Risk factors for TB in Australia and their association with delayed treatment completion. Int J Tuberc Lung Dis 2022; 26:399-405. [PMID: 35505484 PMCID: PMC9067427 DOI: 10.5588/ijtld.21.0111] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: Australia has a low incidence of TB and has committed to eliminating the disease. Identification of risk factors associated with TB is critical to achieving this goal.METHODS: We undertook a prospective cohort study involving persons receiving TB treatment in four Australian jurisdictions. Risk factors and their association with delayed treatment completion (treatment delayed by at least 1 month) were analysed using univariate analyses and multivariate logistic regression.RESULTS: Baseline surveys were completed for 402 persons with TB. Most (86.1%) were born overseas. Exposure to a person with TB was reported by 19.4%. Diabetes mellitus (10.2%), homelessness (9.2%), cigarette smoking (8.7%), excess alcohol consumption (6.0%) and mental illness (6.2%) were other common risk factors. At follow-up, 24.8% of patients had delayed treatment completion, which was associated with adverse events (34.1%, aOR 6.67, 95% CI 3.36-13.27), excess alcohol consumption (6.0%, aOR 21.94, 95% CI 6.03-79.85) and HIV co-infection (2.7%, aOR 8.10, 95% CI 1.16-56.60).CONCLUSIONS: We identified risk factors for TB and their association with delayed treatment completion, not all of which are routinely collected for surveillance purposes. Recognition of these risk factors should facilitate patient-centred care and assist Australia in reaching TB elimination.
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Affiliation(s)
- N J Coorey
- Australian National University Medical School, Canberra ACT, Australia
| | - L Kensitt
- Australian National University Medical School, Canberra ACT, Australia
| | - J Davies
- Australian National University Medical School, Canberra ACT, Australia
| | - E Keller
- Australian National University Medical School, Canberra ACT, Australia
| | - M Sheel
- Research School of Population Health, Australian National University College of Health and Medicine, Australian National University, Canberra ACT, Australia
| | - K Chani
- Research School of Population Health, Australian National University College of Health and Medicine, Australian National University, Canberra ACT, Australia
| | - S Barry
- South Australia Health, Adelaide, SA, Australia
| | - R Boyd
- Northern Territory Health, Darwin, NT, Australia
| | - J Denholm
- Victorian Tuberculosis Program, Melbourne Health, VIC, Australia, Department of Infectious Diseases, Doherty Institute, The University of Melbourne, VIC, Australia
| | - K Watts
- Victorian Tuberculosis Program, Melbourne Health, VIC, Australia
| | - G Fox
- Sydney Medical School-Central, The University of Sydney, Sydney, NSW, Australia
| | - C Lowbridge
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - R Perera
- Western Australia Health, Perth, WA, Australia
| | - J Waring
- Western Australia Health, Perth, WA, Australia, Western Australia Tuberculosis Control Program, Perth, WA, Australia
| | - B Marais
- Centre for Research Excellence in Tuberculosis (TB-CRE), The University of Sydney, Sydney, NSW, Australia, Marie Bashir Institute for Infectious Diseases and Biosecurity (MBI), The University of Sydney, Sydney, NSW, Australia
| | - K Viney
- Research School of Population Health, Australian National University College of Health and Medicine, Australian National University, Canberra ACT, Australia, School of Public Health, The University of Sydney, Sydney, NSW, Australia, Department of Global Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Mejia AJ, Dutra HLC, Jones MJ, Perera R, McGraw EA. Cross-tissue and generation predictability of relative Wolbachia densities in the mosquito Aedes aegypti. Parasit Vectors 2022; 15:128. [PMID: 35413938 PMCID: PMC9004076 DOI: 10.1186/s13071-022-05231-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/03/2022] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The insect endosymbiotic bacterium Wolbachia is being deployed in field populations of the mosquito Aedes aegypti for biological control. This microbe prevents the replication of human disease-causing viruses inside the vector, including dengue, Zika and chikungunya. Relative Wolbachia densities may in part predict the strength of this 'viral blocking' effect. Additionally, Wolbachia densities may affect the strength of the reproductive manipulations it induces, including cytoplasmic incompatibility (CI), maternal inheritance rates or induced fitness effects in the insect host. High rates of CI and maternal inheritance and low rates of fitness effects are also key to the successful spreading of Wolbachia through vector populations and its successful use in biocontrol. The factors that control Wolbachia densities are not completely understood. METHODS We used quantitative PCR-based methods to estimate relative density of the Wolbachia wAlbB strain in both the somatic and reproductive tissues of adult male and female mosquitoes, as well as in eggs. Using correlation analyses, we assessed whether densities in one tissue predict those in others within the same individual, but also across generations. RESULTS We found little relationship among the relative Wolbachia densities of different tissues in the same host. The results also show that there was very little relationship between Wolbachia densities in parents and those in offspring, both in the same and different tissues. The one exception was with ovary-egg relationships, where there was a strong positive association. Relative Wolbachia densities in reproductive tissues were always greater than those in the somatic tissues. Additionally, the densities were consistent in females over their lifetime regardless of tissue, whereas they were generally higher and more variable in males, particularly in the testes. CONCLUSIONS Our results indicate that either stochastic processes or local tissue-based physiologies are more likely factors dictating Wolbachia densities in Ae. aegypti individuals, rather than shared embryonic environments or heritable genetic effects of the mosquito genome. These findings have implications for understanding how relative Wolbachia densities may evolve and/or be maintained over the long term in Ae. aegypti.
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Affiliation(s)
- Austin J. Mejia
- grid.29857.310000 0001 2097 4281Department of Entomology, The Pennsylvania State University, University Park, PA 16802 USA ,grid.29857.310000 0001 2097 4281The Center for Infectious Disease Dynamics, The Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802 USA
| | - H. L. C. Dutra
- grid.29857.310000 0001 2097 4281The Center for Infectious Disease Dynamics, The Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802 USA ,grid.29857.310000 0001 2097 4281Department of Biology, The Pennsylvania State University, University Park, PA 16802 USA
| | - M. J. Jones
- grid.29857.310000 0001 2097 4281The Center for Infectious Disease Dynamics, The Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802 USA ,grid.29857.310000 0001 2097 4281Department of Biology, The Pennsylvania State University, University Park, PA 16802 USA
| | - R. Perera
- grid.47894.360000 0004 1936 8083Center for Vector-Borne Infectious Diseases, Colorado State University, Fort Collins, CO 80523 USA
| | - E. A. McGraw
- grid.29857.310000 0001 2097 4281Department of Entomology, The Pennsylvania State University, University Park, PA 16802 USA ,grid.29857.310000 0001 2097 4281The Center for Infectious Disease Dynamics, The Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802 USA ,grid.29857.310000 0001 2097 4281Department of Biology, The Pennsylvania State University, University Park, PA 16802 USA
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Ryan MS, Khamishon R, Richards A, Perera R, Garber A, Santen SA. A Question of Scale? Generalizability of the Ottawa and Chen Scales to Render Entrustment Decisions for the Core EPAs in the Workplace. Acad Med 2022; 97:552-561. [PMID: 34074896 DOI: 10.1097/acm.0000000000004189] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE Assessments of the Core Entrustable Professional Activities (Core EPAs) are based on observations of supervisors throughout a medical student's progression toward entrustment. The purpose of this study was to compare generalizability of scores from 2 entrustment scales: the Ottawa Surgical Competency Operating Room Evaluation (Ottawa) scale and an undergraduate medical education supervisory scale proposed by Chen and colleagues (Chen). A secondary aim was to determine the impact of frequent assessors on generalizability of the data. METHOD For academic year 2019-2020, the Virginia Commonwealth University School of Medicine modified a previously described workplace-based assessment (WBA) system developed to provide feedback for the Core EPAs across clerkships. The WBA scored students' performance using both Ottawa and Chen scales. Generalizability (G) and decision (D) studies were performed using an unbalanced random-effects model to determine the reliability of each scale. Secondary G- and D-studies explored whether faculty who rated more than 5 students demonstrated better reliability. The Phi-coefficient was used to estimate reliability; a cutoff of at least 0.70 was used to conduct D-studies. RESULTS Using the Ottawa scale, variability attributable to the student ranged from 0.8% to 6.5%. For the Chen scale, student variability ranged from 1.8% to 7.1%. This indicates the majority of variation was due to the rater (42.8%-61.3%) and other unexplained factors. Between 28 and 127 assessments were required to obtain a Phi-coefficient of 0.70. For 2 EPAs, using faculty who frequently assessed the EPA improved generalizability, requiring only 5 and 13 assessments for the Chen scale. CONCLUSIONS Both scales performed poorly in terms of learner-attributed variance, with some improvement in 2 EPAs when considering only frequent assessors using the Chen scale. Based on these findings in conjunction with prior evidence, the authors provide a root cause analysis highlighting challenges with WBAs for Core EPAs.
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Affiliation(s)
- Michael S Ryan
- M.S. Ryan is associate professor and assistant dean for clinical medical education, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia; ORCID: https://orcid.org/0000-0003-3266-9289
| | - Rebecca Khamishon
- R. Khamishon is a fourth-year medical student, Virginia Commonwealth University, Richmond, Virginia
| | - Alicia Richards
- A. Richards is a graduate student, Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Robert Perera
- R. Perera is associate professor, Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Adam Garber
- A. Garber is associate professor, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia; ORCID: https://orcid.org/0000-0002-7296-2896
| | - Sally A Santen
- S.A. Santen is professor and senior associate dean of assessment, evaluation, and scholarship, Department of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia; ORCID: https://orcid.org/0000-0002-8327-8002
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Roy S, Min A, Khan O, Perera R, Jovin IS. CRT-500.08 Phosphodiesterase 5 Inhibitors and the Risk of Nephropathy and Long-Term Outcomes After Coronary Angiography and Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2022. [DOI: 10.1016/j.jcin.2022.01.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Trost Z, Anam M, Seward J, Shum C, Rumble D, Sturgeon J, Mark V, Chen Y, Mitchell L, Cowan R, Perera R, Richardson E, Richards S, Gustin S. Immersive interactive virtual walking reduces neuropathic pain in spinal cord injury: findings from a preliminary investigation of feasibility and clinical efficacy. Pain 2022; 163:350-361. [PMID: 34407034 DOI: 10.1097/j.pain.0000000000002348] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/15/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic neuropathic pain (NP) is a common and often debilitating secondary condition for persons with spinal cord injury (SCI) and is minimally responsive to existing pharmacological and nonpharmacological treatments. The current preliminary investigation describes the feasibility and initial comparative efficacy of an interactive virtual reality walking intervention, which is a novel extension of visual feedback/illusory walking therapies shown to reduce SCI NP. Virtual reality walking intervention builds on previous research by, for the first time, allowing individuals with SCI NP to volitionally control virtual gait to interact with a fully immersive virtual environment. The current pilot study compared this interactive, virtual walking intervention to a passive, noninteractive virtual walking condition (analogous to previous illusory walking interventions) in 27 individuals with complete paraplegia (interactive condition, n = 17; passive condition, n = 10; nonrandomized design). The intervention was delivered over 2 weeks in individuals' homes. Participants in the interactive condition endorsed significantly greater reductions in NP intensity and NP-related activity interference preintervention to postintervention. Notable improvements in mood and affect were also observed both within individual sessions and in response to the full intervention. These results, although preliminary, highlight the potentially potent effects of an interactive virtual walking intervention for SCI NP. The current study results require replication in a larger, randomized clinical trial and may form a valuable basis for future inquiry regarding the mechanisms and clinical applications of virtual walking therapies.
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Affiliation(s)
- Zina Trost
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Monima Anam
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Joshua Seward
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Corey Shum
- Immersive Experience Labs, Birmingham, AL, United States
| | - Deanna Rumble
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - John Sturgeon
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Victor Mark
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Yuying Chen
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Lucie Mitchell
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Rachel Cowan
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Robert Perera
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | | | - Scott Richards
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Sylvia Gustin
- School of Psychology, University of New South Wales, Sydney, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
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Patel E, Mascarenhas A, Ahmed S, Stirt D, Brady I, Perera R, Noël J. Evaluating the ability of students to learn and utilize a novel telepresence platform, proximie. EUR UROL SUPPL 2021. [DOI: 10.1016/s2666-1683(21)02314-4] [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] Open
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Ryan MS, Khamishon R, Richards A, Perera R, Garber A, Santen SA. A Question of Scale? Comparison of Generalizability in Ottawa and Chen Scales When Used to Formulate Ad Hoc Entrustment Decisions for the Core EPAs. Acad Med 2021; 96:S214-S215. [PMID: 34705716 DOI: 10.1097/acm.0000000000004282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Michael S Ryan
- Author affiliations: M.S. Ryan, R. Khamishon, A. Richards, R. Perera, A. Garber, S.A. Santen, Virginia Commonwealth University School of Medicine
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Ryan MS, Richards A, Perera R, Park YS, Stringer JK, Waterhouse E, Dubinsky B, Khamishon R, Santen SA. Generalizability of the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) Scale to Assess Medical Student Performance on Core EPAs in the Workplace: Findings From One Institution. Acad Med 2021; 96:1197-1204. [PMID: 33464735 DOI: 10.1097/acm.0000000000003921] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE Assessment of the Core Entrustable Professional Activities for Entering Residency (Core EPAs) requires direct observation of learners in the workplace to support entrustment decisions. The purpose of this study was to examine the internal structure validity evidence of the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) scale when used to assess medical student performance in the Core EPAs across clinical clerkships. METHOD During the 2018-2019 academic year, the Virginia Commonwealth University School of Medicine implemented a mobile-friendly, student-initiated workplace-based assessment (WBA) system to provide formative feedback for the Core EPAs across all clinical clerkships. Students were required to request a specified number of Core EPA assessments in each clerkship. A modified O-SCORE scale (1 = "I had to do" to 4 = "I needed to be in room just in case") was used to rate learner performance. Generalizability theory was applied to assess the generalizability (or reliability) of the assessments. Decision studies were then conducted to determine the number of assessments needed to achieve a reasonable reliability. RESULTS A total of 10,680 WBAs were completed on 220 medical students. The majority of ratings were completed on EPA 1 (history and physical) (n = 3,129; 29%) and EPA 6 (oral presentation) (n = 2,830; 26%). Mean scores were similar (3.5-3.6 out of 4) across EPAs. Variance due to the student ranged from 3.5% to 8%, with the majority of the variation due to the rater (29.6%-50.3%) and other unexplained factors. A range of 25 to 63 assessments were required to achieve reasonable reliability (Phi > 0.70). CONCLUSIONS The O-SCORE demonstrated modest reliability when used across clerkships. These findings highlight specific challenges for implementing WBAs for the Core EPAs including the process for requesting WBAs, rater training, and application of the O-SCORE scale in medical student assessment.
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Affiliation(s)
- Michael S Ryan
- M.S. Ryan is associate professor and assistant dean for clinical medical education, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia; ORCID: https://orcid.org/0000-0003-3266-9289
| | - Alicia Richards
- A. Richards is a graduate student, Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Robert Perera
- R. Perera is associate professor, Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Yoon Soo Park
- Y.S. Park is associate professor and associate head, Department of Medical Education, University of Illinois College of Medicine, Chicago, Illinois
| | - J K Stringer
- J.K. Stringer is assessment manager, Office of Integrated Medical Education, Rush Medical College, Chicago, Illinois
| | - Elizabeth Waterhouse
- E. Waterhouse is professor, Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Brieanne Dubinsky
- B. Dubinsky is business analyst, Office of Academic Information Systems, Virginia Commonwealth University, Richmond, Virginia
| | - Rebecca Khamishon
- R. Khamishon is a third-year medical student, Virginia Commonwealth University, Richmond, Virginia
| | - Sally A Santen
- S.A. Santen is professor and senior associate dean of assessment, evaluation, and scholarship, Department of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia; ORCID: https://orcid.org/0000-0002-8327-8002
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15
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García I, Suárez E, Maiz N, Pascual M, Perera R, Arévalo S, Giné C, Molino JA, López M, Carreras E, Manrique S. Fetal heart rate monitoring during fetoscopic repair of open spinal neural tube defects: a single-centre observational cohort study. Int J Obstet Anesth 2021; 48:103195. [PMID: 34175576 DOI: 10.1016/j.ijoa.2021.103195] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 04/23/2021] [Accepted: 05/31/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND During fetal surgery, the haemodynamic stability of the fetus depends on the haemodynamic stability of the mother. The primary objective of this study was to assess changes in fetal heart rate (FHR) throughout the different stages of surgery. The secondary objective was to assess potential changes in maternal physiological parameters and their association with FHR. METHODS This was a single-center observational cohort study conducted between 2015 and 2019 in 26 women undergoing intra-uterine fetoscopic repair of open spina bifida. The primary outcome was FHR. Maternal physiologic parameters were measured at the beginning, during and after surgery. The linear mixed-effects model fitted by maximum likelihood was used to assess changes in each variable at specific times throughout the surgery, and the repeated measures correlation coefficient was used to study the association between FHR and maternal physiological parameters. RESULTS One (3.8%) case of fetal bradycardia (FHR <110 beats per minute) required the administration of intramuscular atropine. No other significant FHR changes were observed during surgery. Maternal oesophageal temperature (P <0.001), lactate levels (P=0.002), and mean arterial pressure (P=0.016) changed significantly during surgery, although none of these changes was clinically relevant. The FHR showed a significant association with maternal carbon dioxide tension (r=0.285, 95% CI 0.001 to 0.526) and maternal heart rate (r=0.302, 95% CI 0.025 to 0.535). CONCLUSION The FHR remained stable during intra-uterine fetoscopic repair of open spina bifida. Maternal carbon dioxide tension and heart rate may have a mild influence on FHR.
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Affiliation(s)
- I García
- Anaesthesiology and Intensive Care Department. Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - E Suárez
- Anaesthesiology and Intensive Care Department. Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - N Maiz
- Universitat Autònoma de Barcelona, Bellaterra, Spain; Obstetrics Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
| | - M Pascual
- Anaesthesiology and Intensive Care Department. Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - R Perera
- Anaesthesiology and Intensive Care Department. Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - S Arévalo
- Universitat Autònoma de Barcelona, Bellaterra, Spain; Obstetrics Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - C Giné
- Universitat Autònoma de Barcelona, Bellaterra, Spain; Paediatric Surgery Department. Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus. Barcelona, Spain
| | - J A Molino
- Universitat Autònoma de Barcelona, Bellaterra, Spain; Paediatric Surgery Department. Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus. Barcelona, Spain
| | - M López
- Universitat Autònoma de Barcelona, Bellaterra, Spain; Paediatric Surgery Department. Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus. Barcelona, Spain
| | - E Carreras
- Universitat Autònoma de Barcelona, Bellaterra, Spain; Obstetrics Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - S Manrique
- Anaesthesiology and Intensive Care Department. Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra, Spain
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Vélez E, Carnicero A, Perera R. Elemental Crack Advance assessment and verification for its use in LBB analysis. Nuclear Engineering and Design 2020. [DOI: 10.1016/j.nucengdes.2020.110622] [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: 11/30/2022]
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Layon DR, Johns WL, Morrell AT, Perera R, Patel NK, Golladay GJ, Kates SL. Does Adherence to Preoperative Surgical Selection Criteria Reduce the Rate of Prosthetic Joint Infection in Primary and Revision Total Knee Arthroplasties? Arthroplast Today 2020; 6:410-413. [PMID: 32577486 PMCID: PMC7305334 DOI: 10.1016/j.artd.2020.04.019] [Citation(s) in RCA: 5] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/23/2020] [Accepted: 04/29/2020] [Indexed: 01/01/2023] Open
Abstract
Background There has been recent increased focus on the importance of modifiable risk factors that can affect the risk of potentially avoidable complications such as prosthetic joint infection (PJI). We aimed to assess the relationship between adherence to a preoperative optimization protocol at our institution and its influence on the rate of PJI after primary and revision total knee arthroplasty (TKA). Methods A single-institution, retrospective study was conducted on all elective primary and revision TKAs performed over a 2-year period. PJI was diagnosed using the 2011 Musculoskeletal Infection Society criteria. Surgical outcomes and PJI were assessed relative to adherence to preoperative optimization criteria. Compliance was set as a binary variable with any case that did not meet all criteria deemed noncompliant. Results A total of 669 TKAs met inclusion criteria, including 510 primary and 159 revision TKAs. Overall compliance was 61.3%. There were 26 PJIs (3.9%) in total. The PJI rate was 1.2% (6) among primary and 14.4% (20) among revision TKAs. The rate of PJI among cases that met the preoperative optimization criteria was 2.4% (5), and the rate among cases that did not was 6.2% (21) (P < .05). Conclusions Adherence to preoperative optimization criteria may decrease the incidence of PJI after primary and revision TKA, but further study is needed to confirm the findings of this study.
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Affiliation(s)
- Daniel R Layon
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - William L Johns
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Aidan T Morrell
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Robert Perera
- Department of Biostatistics, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Nirav K Patel
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
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Riddle D, Perera R. Use of tanezumab for patients with hip and knee osteoarthritis with reference to a randomised clinical trial by Berenbaum and colleagues. Ann Rheum Dis 2020; 81:e65. [PMID: 32321719 DOI: 10.1136/annrheumdis-2020-217526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Daniel Riddle
- Department of Physical Therapy, Ortho Surgery and Rheumatology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Robert Perera
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
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Riddle D, Perera R. The Western Ontario and Mcmaster Universities arthritis index pain scale demonstrates cross talk from co-occurring pain sites in persons with knee pain: a cross-sectional multicenter study. Osteoarthritis Cartilage 2020. [DOI: 10.1016/j.joca.2020.02.563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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20
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Gondwe T, Perera R. A multiple-group confirmatory factor analysis of psychosocial stressors among Medicaid-covered pregnant women. Ann Epidemiol 2019. [DOI: 10.1016/j.annepidem.2019.06.053] [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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21
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Shinkins B, Primrose JN, Pugh SA, Nicholson BD, Perera R, James T, Man D. Serum carcinoembryonic antigen trends for diagnosing colorectal cancer recurrence in the FACS randomized clinical trial. Br J Surg 2019; 106:728. [DOI: 10.1002/bjs.11175] [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: 11/07/2022]
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22
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Chandrasiri N, Rajanthi R, Sathanandaraja R, Perera R, Wijethunga G, Gilbey T, Balaghom R, Branley J, Samarasekara H. Phenotypic and molecular characterisation of outbreak strain of Enterobacter clocae in a special care baby unit (SCBU), Colombo South Teaching Hospital (CSTH), Sri lanka. Pathology 2019. [DOI: 10.1016/j.pathol.2018.12.408] [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: 10/27/2022]
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23
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Perera R, Oliver N, Wilmot E, Marriott C. Variations in access to and reimbursement for continuous glucose monitoring systems for people living with Type 1 diabetes across England. Diabet Med 2018; 35:1617-1618. [PMID: 29931731 DOI: 10.1111/dme.13766] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2018] [Indexed: 11/28/2022]
Affiliation(s)
- R Perera
- Wicked Minds Ltd, Windsor, Berkshire
| | - N Oliver
- Institute of Biomedical Engineering, Imperial College London, London
| | - E Wilmot
- Department of Diabetes, Derby Teaching Hospitals NHS Foundation Trust, Derby
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Prabhakar K, Rodrguez C, Jayanthy A, Perera R, Setaluri V. 1233 Relationship of the oncogenic role of miR-214 to regulation of β-catenin in melanoma. J Invest Dermatol 2018. [DOI: 10.1016/j.jid.2018.03.1248] [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: 10/17/2022]
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Lee R, Jarchi D, Perera R, Jones A, Cassimjee I, Handa A, Clifton DA. Applied Machine Learning for the Prediction of Growth of Abdominal Aortic Aneurysm in Humans. EJVES Short Rep 2018; 39:24-28. [PMID: 29988820 PMCID: PMC6033055 DOI: 10.1016/j.ejvssr.2018.03.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/15/2018] [Accepted: 03/25/2018] [Indexed: 01/16/2023] Open
Abstract
Objective Accurate prediction of abdominal aortic aneurysm (AAA) growth in an individual can allow personalised stratification of surveillance intervals and better inform the timing for surgery. The authors recently described the novel significant association between flow mediated dilatation (FMD) and future AAA growth. The feasibility of predicting future AAA growth was explored in individual patients using a set of benchmark machine learning techniques. Methods The Oxford Abdominal Aortic Aneurysm Study (OxAAA) prospectively recruited AAA patients undergoing the routine NHS management pathway. In addition to the AAA diameter, FMD was systemically measured in these patients. A benchmark machine learning technique (non-linear Kernel support vector regression) was applied to predict future AAA growth in individual patients, using their baseline FMD and AAA diameter as input variables. Results Prospective growth data were recorded at 12 months (360 ± 49 days) in 94 patients. Of these, growth data were further recorded at 24 months (718 ± 81 days) in 79 patients. The average growth in AAA diameter was 3.4% at 12 months, and 2.8% per year at 24 months. The algorithm predicted the individual's AAA diameter to within 2 mm error in 85% and 71% of patients at 12 and 24 months. Conclusions The data highlight the utility of FMD as a biomarker for AAA and the value of machine learning techniques for AAA research in the new era of precision medicine. Flow mediated dilatation of brachial artery is a biomarker of AAA progression. It is feasible to predict future AAA growth in individuals using machine learning techniques. Endothelial dysfunction is a key feature in human AAA disease.
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Affiliation(s)
- R Lee
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - D Jarchi
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - R Perera
- Nuffield Department of Primary Care Health, University of Oxford, Oxford, UK
| | - A Jones
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - I Cassimjee
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - A Handa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - D A Clifton
- Nuffield Department of Primary Care Health, University of Oxford, Oxford, UK
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Riddle DL, Jensen MP, Ang D, Slover J, Perera R, Dumenci L. Do Pain Coping and Pain Beliefs Associate With Outcome Measures Before Knee Arthroplasty in Patients Who Catastrophize About Pain? A Cross-sectional Analysis From a Randomized Clinical Trial. Clin Orthop Relat Res 2018. [PMID: 29543659 PMCID: PMC6260056 DOI: 10.1007/s11999.0000000000000001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pain-coping strategies and appraisals are responses to the pain experience. They can influence patient-reported and physical performance outcome measures in a variety of disorders, but the associations between a comprehensive profile of pain-coping responses and preoperative pain/function and physical performance measures in patients scheduled for knee arthroplasty have not been examined. Patients with moderate to high pain catastrophizing (a pain appraisal approach associated with an exaggerated focus on the threat value of pain) may represent an excellent study population in which to address this knowledge gap. QUESTIONS/PURPOSES We asked the following questions among patients with high levels of pain catastrophizing who were scheduled for TKA: (1) Do maladaptive pain responses correlate with worse self-reported pain intensity and function and physical performance? (2) Do adaptive pain-coping responses show the opposite pattern? As an exploratory hypothesis, we also asked: (3) Do maladaptive responses show more consistent associations with measures of pain, function, and performance as compared with adaptive responses? METHODS A total of 384 persons identified with moderate to high levels of pain catastrophizing and who consented to have knee arthroplasty were recruited. The sample was 67% (257 of 384) women and the mean age was 63 years. Subjects were consented between 1 and 8 weeks before scheduled surgery. All subjects completed the WOMAC pain and function scales in addition to a comprehensive profile of pain coping and appraisal measures and psychologic health measures. Subjects also completed the Short Physical Performance Battery and the 6-minute walk test. For the current study, all measures were obtained at a single point in time at the preoperative visit with no followup. Multilevel multivariate multiple regression was used to test the hypotheses and potential confounders were adjusted for in the models. RESULTS Maladaptive pain responses were associated with worse preoperative pain and function measures. For example, the maladaptive pain-coping strategy of guarding and the pain catastrophizing appraisal measures were associated with WOMAC pain scores such that higher guarding scores (β = 0.12, p = 0.007) and higher pain catastrophizing (β = 0.31, p < 0.001) were associated with worse WOMAC pain; no adaptive responses were associated with better WOMAC pain or physical performance scores. Maladaptive responses were also more consistently associated with worse self-reported and performance-based measure scores (six of 16 associations were significant in the hypothesized direction), whereas adaptive responses did not associate with better scores (zero of 16 scores were significant in the hypothesized direction). CONCLUSIONS The maladaptive responses of guarding, resting, and pain catastrophizing were associated with worse scores on preoperative pain and performance measures. These are pain-related responses surgeons should consider when assessing patients before knee arthroplasty. TKA candidates found to have these pain responses may be targets for treatments that may improve postoperative outcome given that these responses are modifiable. Future intervention-based research should target this trio of maladaptive pain responses to determine if intervention leads to improvements in postsurgical health outcomes. LEVEL OF EVIDENCE Level I, prognostic study.
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Affiliation(s)
- Daniel L Riddle
- D. L. Riddle Departments of Physical Therapy, Orthopaedic Surgery and Rheumatology, Virginia Commonwealth University, Richmond, VA, USA M. P. Jensen Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA D. Ang Department of Medicine, Section of Rheumatology, Wake Forest School of Medicine, Winston-Salem, NC, USA J. Slover Department of Orthopaedic Surgery, New York University Medical Center, New York, NY, USA R. Perera Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA L. Dumenci Department of Epidemiology and Biostatistics, Temple University, Philadelphia, PA, USA
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27
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Shinkins B, Primrose JN, Pugh SA, Nicholson BD, Perera R, James T, Mant D. Serum carcinoembryonic antigen trends for diagnosing colorectal cancer recurrence in the FACS randomized clinical trial. Br J Surg 2018; 105:658-662. [PMID: 29579327 DOI: 10.1002/bjs.10819] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 10/23/2017] [Accepted: 12/13/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Most guidelines recommend that patients who have undergone curative resection for primary colorectal cancer are followed up for 5 years with regular blood carcinoembryonic antigen (CEA) tests to trigger further investigation for recurrence. However, CEA may miss recurrences, or patients may have false alarms and undergo unnecessary investigation. METHODS The diagnostic accuracy of trends in CEA measurements for recurrent colorectal cancer, taken as part of the FACS (Follow-up After Colorectal Surgery) trial (2003-2014), were analysed. Investigation to detect recurrence was triggered by clinical symptoms, scheduled CT or colonoscopy, or a CEA level of at least 7 μg/l above baseline. Time-dependent receiver operating characteristic (ROC) curve analysis was used to compare the diagnostic accuracy of CEA trends with single measurements. CEA trends were estimated using linear regression. RESULTS The area under the ROC curve (AUC) for CEA trend was at least 0·820 across all 5 years of follow-up. In comparison, the AUCs for single measurements ranged from 0·623 to 0·749. Improvement was most marked at the end of the first year of follow-up, with the AUC increasing from 0·623 (95 per cent c.i. 0·509 to 0·736) to 0·880 (0·814 to 0·947). However, no individual trend threshold achieved a sensitivity above 70 per cent (30 per cent missed recurrences). CONCLUSION Interpreting trends in CEA measurements instead of single CEA test results improves diagnostic accuracy for recurrence, but not sufficiently to warrant it being used as a single surveillance strategy to trigger further investigation. In the absence of a more accurate biomarker, monitoring trends in CEA should be combined with clinical, endoscopic and imaging surveillance for improved accuracy.
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Affiliation(s)
- B Shinkins
- Test Evaluation Group, Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - J N Primrose
- University Surgery, University of Southampton, Southampton, UK
| | - S A Pugh
- University Surgery, University of Southampton, Southampton, UK
| | - B D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - R Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - T James
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D Mant
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Hoffmann T, Glasziou P, Boutron I, Milne R, Perera R, Moher D, Altman D, Barbour V, Macdonald H, Johnston M, Lamb S, Dixon-Woods M, McCulloch P, Wyatt J, Chan AW, Michie S. Die TIDieR Checkliste und Anleitung – ein Instrument für eine verbesserte Interventionsbeschreibung und Replikation. Gesundheitswesen 2018; 78:e174. [DOI: 10.1055/s-0037-1600948] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- T. Hoffmann
- Centre for Research in Evidence Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia, 4229
| | - P. Glasziou
- Centre for Research in Evidence Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia, 4229
| | - I. Boutron
- INSERMU738, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - R. Milne
- Wessex Institute, University of Southampton, Southampton, UK
| | - R. Perera
- Department of Primary Care Health Sciences, University of Oxford, UK
| | - D. Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - D. Altman
- Centre for Statistics in Medicine, University of Oxford, UK
| | | | | | - M. Johnston
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - S. Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - M. Dixon-Woods
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - P. McCulloch
- Nuffield Department of Surgical Science, University of Oxford, Oxford, UK
| | - J. Wyatt
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - A.-W. Chan
- Women’s College Research Institute, University of Toronto, Toronto, Canada
| | - S. Michie
- Centre for Outcomes Research and Effectiveness, Department of Clinical, Educational and Health Psychology, University College London, London, UK
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Nicholson BD, Aveyard P, Hobbs FDR, Smith M, Fuller A, Perera R, Hamilton W, Stevens S, Bankhead CR. Weight loss as a predictor of cancer and serious disease in primary care: an ISAC-approved CPRD protocol for a retrospective cohort study using routinely collected primary care data from the UK. Diagn Progn Res 2018; 2:1. [PMID: 31093551 PMCID: PMC6460783 DOI: 10.1186/s41512-017-0019-9] [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] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 11/16/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Unexpected weight loss is a symptom of serious disease in primary care, for example between 1 in 200 and 1 in 30 patients with unexpected weight loss go on to develop cancer. However, it remains unclear how and when general practitioners (GPs) should investigate unexpected weight loss. Without clarification, GPs may wait too long before referring (choosing to watch and wait and potentially missing a diagnosis) or not long enough (overburdening hospital services and exposing patients to the risks of investigation). The overall aim of this study is to provide the evidence necessary to allow GPs to more effectively manage patients with unexpected weight loss. METHODS A retrospective cohort analysis of UK Clinical Practice Research Datalink (CPRD) data to: (1) describe how often in UK primary care the symptom of reported weight loss is coded, when weight is measured, and how GPs respond to a patient attending with unexpected weight loss; (2) identify the predictive value of recorded weight loss for cancer and serious disease in primary care, using cumulative incidence plots to compare outcomes between subgroups and Cox regression to explore and adjust for covariates. Preliminary work in CPRD estimates that weight loss as a symptom is recorded for approximately 148,000 eligible patients > 18 years and is distributed evenly across decades of age, providing adequate statistical power and precision in relation to cancer overall and common cancers individually. Further stratification by cancer stage will be attempted but may not be possible as not all practices within CPRD are eligible for cancer registry linkage, and staging information is often incomplete. The feasibility of using multiple imputation to address missing covariate values will be explored. DISCUSSION This will be the largest reported retrospective cohort of primary care patients with weight measurements and unexpected weight loss codes used to understand the association between weight measurement, unexpected weight loss, and serious disease including cancer. Our findings will directly inform international guidelines for the management of unexpected weight loss in primary care populations.
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Affiliation(s)
- B. D. Nicholson
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - P. Aveyard
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - F. D. R. Hobbs
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - M. Smith
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - A. Fuller
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - R. Perera
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - W. Hamilton
- 0000 0004 1936 8024grid.8391.3University of Exeter, Medical School, St Luke’s Campus, Exeter, EX1 2LU UK
| | - S. Stevens
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - C. R. Bankhead
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
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Affiliation(s)
- N.S. Ningaraj
- Department of Pediatric Neurooncology and Molecular Pharmacology, Hoskins Center, Curtis and Elizabeth Anderson Cancer Institute, Memorial Health University Medical Center, Mercer University Medical School, 4700 Waters Avenue, Savannah, GA 31404, U.S.A
| | - B.P. Salimath
- Department of Biotechnology, University of Mysore, Mysore 570006, Karnataka, India
| | - U.T. Sankpal
- Department of Pediatric Neurooncology and Molecular Pharmacology, Hoskins Center, Curtis and Elizabeth Anderson Cancer Institute, Memorial Health University Medical Center, Mercer University Medical School, 4700 Waters Avenue, Savannah, GA 31404, U.S.A
| | - R Perera
- Department of Pediatric Neurooncology and Molecular Pharmacology, Hoskins Center, Curtis and Elizabeth Anderson Cancer Institute, Memorial Health University Medical Center, Mercer University Medical School, 4700 Waters Avenue, Savannah, GA 31404, U.S.A
| | - T Vats
- Department of Pediatric Neurooncology and Molecular Pharmacology, Hoskins Center, Curtis and Elizabeth Anderson Cancer Institute, Memorial Health University Medical Center, Mercer University Medical School, 4700 Waters Avenue, Savannah, GA 31404, U.S.A
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Pugh S, Mant D, Shinkins B, Mellor J, Perera R, Primrose J. Scheduled use of CEA and CT follow-up to detect recurrence of colorectal cancer: 6-12 year results from the FACS randomised controlled trial. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw370.02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, Altman DG, Barbour V, Macdonald H, Johnston M, Lamb SE, Dixon-Woods M, McCulloch P, Wyatt JC, Chan AW, Michie S. [Better Reporting of Interventions: Template for Intervention Description and Replication (TIDieR) Checklist and Guide]. Gesundheitswesen 2016; 78:175-88. [PMID: 26824401 DOI: 10.1055/s-0041-111066] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Without a complete published description of interventions, clinicians and patients cannot reliably implement interventions that are shown to be useful, and other researchers cannot replicate or build on research findings. The quality of description of interventions in publications, however, is remarkably poor. To improve the completeness of reporting, and ultimately the replicability, of interventions, an international group of experts and stakeholders developed the Template for Intervention Description and Replication (TIDieR) checklist and guide. The process involved a literature review for relevant checklists and research, a Delphi survey of an international panel of experts to guide item selection, and a face-to-face panel meeting. The resultant 12-item TIDieR checklist (brief name, why, what (materials), what (procedure), who intervened, how, where, when and how much, tailoring, modifications, how well (planned), how well (actually carried out)) is an extension of the CONSORT 2010 statement (item 5) and the SPIRIT 2013 statement (item 11). While the emphasis of the checklist is on trials, the guidance is intended to apply across all evaluative study designs. This paper presents the TIDieR checklist and guide, with a detailed explanation of each item, and examples of good reporting. The TIDieR checklist and guide should improve the reporting of interventions and make it easier for authors to structure the accounts of their interventions, reviewers and editors to assess the descriptions, and readers to use the information.
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Affiliation(s)
- T C Hoffmann
- Centre for Research in Evidence Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia, 4229
| | - P P Glasziou
- Centre for Research in Evidence Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia, 4229
| | - I Boutron
- INSERMU738, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - R Milne
- Wessex Institute, University of Southampton, Southampton, UK
| | - R Perera
- Department of Primary Care Health Sciences, University of Oxford, UK
| | - D Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - D G Altman
- Centre for Statistics in Medicine, University of Oxford, UK
| | | | | | - M Johnston
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - S E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - M Dixon-Woods
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - P McCulloch
- Nuffield Department of Surgical Science, University of Oxford, Oxford, UK
| | - J C Wyatt
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - A-W Chan
- Women's College Research Institute, University of Toronto, Toronto, Canada
| | - S Michie
- Centre for Outcomes Research and Effectiveness, Department of Clinical, Educational and Health Psychology, University College London, London, UK
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Wang LM, Guy R, Fryer E, Kartsonaki C, Gill P, Hughes C, Szuts A, Perera R, Chetty R, Mortensen N. The Ueno method for substaging pT1 colorectal adenocarcinoma by depth and width measurement: an interobserver study. Colorectal Dis 2015; 17:674-81. [PMID: 25620664 DOI: 10.1111/codi.12910] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 10/25/2014] [Indexed: 02/08/2023]
Abstract
AIM Early pT1 polyp colorectal cancers (CRCs) present challenges for accurate pathology substaging. Haggitt and Kikuchi stages depend on polyp morphology and are often difficult to apply due to suboptimal orientation or fragmentation, or absence of the muscularis propria in polypectomy or submucosal resection specimens. European guidelines for quality assurance suggest using Ueno's more objective approach, using depth and width measurements beyond muscularis mucosae. We have investigated interobserver variation using Ueno's approach. METHOD Ten consecutive pT1 polyp CRCs were identified and the slides assessed by six gastrointestinal pathologists for depth and width of invasion. A further 60 polyps were studied by a group of specialist and general pathologists. Agreement was assessed by analysis of variance. A polyp CRC is classified as high risk if it has a depth ≥ 2000 μm or a width ≥ 4000 μm and low risk with a depth < 2000 μm or a width < 4000 μm. Concordance for the dichotomized values was assessed using the kappa statistic. RESULTS The intraclass correlation coefficient (ICC) for depth was 0.83 and for width 0.56 in the 10-polyp group. The ICC for the 60-polyp CRCs was 0.67 for depth and 0.37 for width. In both groups, when polyp CRCs are divided into high- and low-risk categories based on depth, there was substantial and moderate agreement (κ = 0.80 and 0.47) but only fair agreement when based on width (κ = 0.34 and 0.35). CONCLUSION Ueno's method has the advantage of being independent of polyp morphology. Our study shows better concordance for depth measurement and reproducibility in nonfragmented specimens, with poorer agreement when based on width.
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Affiliation(s)
- L M Wang
- Department of Cellular Pathology, John Radcliffe Hospital, University of Oxford, Headington, Oxford, UK
| | - R Guy
- Department of Colorectal Surgery, Churchill Hospital, University of Oxford, Headington, Oxford, UK
| | - E Fryer
- Department of Cellular Pathology, John Radcliffe Hospital, University of Oxford, Headington, Oxford, UK
| | - C Kartsonaki
- CR-UK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, John Radcliffe Hospital, University of Oxford, Headington, Oxford, UK
| | - P Gill
- Department of Cellular Pathology, John Radcliffe Hospital, University of Oxford, Headington, Oxford, UK
| | - C Hughes
- Department of Cellular Pathology, John Radcliffe Hospital, University of Oxford, Headington, Oxford, UK
| | - A Szuts
- Department of Cellular Pathology, John Radcliffe Hospital, University of Oxford, Headington, Oxford, UK
| | - R Perera
- Department of Cellular Pathology, John Radcliffe Hospital, University of Oxford, Headington, Oxford, UK
| | - R Chetty
- Department of Cellular Pathology, John Radcliffe Hospital, University of Oxford, Headington, Oxford, UK
| | - N Mortensen
- Department of Colorectal Surgery, Churchill Hospital, University of Oxford, Headington, Oxford, UK
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Zhou Q, Jackson-Cook C, Lyon D, Perera R, Archer KJ. Identifying molecular features associated with psychoneurological symptoms in women with breast cancer using multivariate mixed models. Cancer Inform 2015; 14:139-45. [PMID: 25983548 PMCID: PMC4426955 DOI: 10.4137/cin.s17276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 11/26/2014] [Revised: 02/15/2015] [Accepted: 02/17/2015] [Indexed: 12/29/2022] Open
Abstract
Breast cancer (BC) is the second most common cancer among women. Research shows many women with BC experience anxiety, depression, and stress (ADS). Epigenetics has recently emerged as a potential mechanism for the development of depression.1 Although there are growing numbers of research studies indicating that epigenetic changes are associated with ADS, there is currently no evidence that this association is present in women with BC. The goal of this study was to identify high-throughput methylation sites (CpG sites) that are associated with three psychoneurological symptoms (ADS) in women with BC. Traditionally, univariate models have been used to examine the relationship between methylation sites and each psychoneurological symptom; nevertheless, ADS can be treated as a cluster of related symptoms and included together in a multivariate linear model. Hence, an overarching goal of this study is to compare and contrast univariate and multivariate models when identifying methylation sites associated with ADS in women with BC. When fitting separate linear regression models for each ADS scale, 3 among 285,173 CpG sites tested were significantly associated with depression. Two significant CpG sites are located on their respective genes FAM101A and FOXJ1, and the third site cannot be mapped to any known gene at this time. In contrast, the multivariate models identified 8,535 ADS-related CpG sites. In conclusion, when analyzing correlated psychoneurological symptom outcomes, multivariate models are more powerful and thus are recommended.
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Affiliation(s)
- Qing Zhou
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Debra Lyon
- College of Nursing, University of Florida, Gainesville, FL, USA
| | - Robert Perera
- Departments of Biostatistics & Social and Behavioral Health, Virginia Commonwealth University, Richmond, VA, USA
| | - Kellie J Archer
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
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35
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Johns D, Hartmann-Boyce J, Langford O, Perera R, Jebb S, Aveyard P. A systematic review of weight regain after behavioural weight management programme end. Appetite 2015. [DOI: 10.1016/j.appet.2014.12.151] [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: 10/24/2022]
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Riddle DL, Perera R, Jiranek WA, Dumenci L. Letter to the editor: preoperative pain and function profiles reflect consistent TKA patient selection among US surgeons. Clin Orthop Relat Res 2015; 473:393-4. [PMID: 25361849 PMCID: PMC4390977 DOI: 10.1007/s11999-014-4035-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/23/2014] [Indexed: 01/31/2023]
Affiliation(s)
- Daniel L Riddle
- Department of Physical Therapy, Virginia Commonwealth University, 12th and Broad Street, Basement, Room b-100, Richmond, VA, 23113, USA,
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37
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Tedelind S, Perera R, Yurtdas Y, Pinzaru A, Szumska J, Rehders M, Scott CJ, Burden R, Führer D, Brix K. Can nuclear cathepsin variants promote tumor progression in the thyroid? Exp Clin Endocrinol Diabetes 2014. [DOI: 10.1055/s-0034-1372033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Doughty RN, Gardin JM, Hobbs FDR, McMurray JJV, Nagueh SF, Poppe KK, Senior R, Thomas L, Whalley GA, Aune E, Brown A, Badano LP, Cameron V, Chadha DS, Chahal N, Chien KL, Daimon M, Dalen H, Detrano R, Akif Duzenli M, Ezekowitz J, de Simone G, Di Pasquale P, Fukuda S, Gill PS, Grossman E, Hobbs FDR, Kim HK, Kuznetsova T, Leung NKW, Linhart A, McDonagh TA, McGrady M, McMurray JJV, Mill JG, Mogelvang R, Muiesan ML, Ng ACT, Ojji D, Otterstad JE, Petrovic DJ, Poppe KK, Prendergast B, Rietzschel E, Schirmer H, Schvartzman P, Senior R, Simova I, Sliwa K, Stewart S, Squire IB, Takeuchi M, Thomas L, Whalley GA, Altman D, Perera R, Poppe KK, Triggs CM, Au Yeung H, Beans Picon GA, Poppe KK, Whalley GA. A meta-analysis of echocardiographic measurements of the left heart for the development of normative reference ranges in a large international cohort: the EchoNoRMAL study. Eur Heart J Cardiovasc Imaging 2013; 15:341-8. [DOI: 10.1093/ehjci/jet240] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Martinez-Devesa P, Perera R, Theodoulou M, Waddell A. [Cognitive behavioural therapy for tinnitus]. Arch Prev Riesgos Labor 2013; 16:96-97. [PMID: 23700710] [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: 06/02/2023] Open
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40
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Heneghan C, Blacklock C, Perera R, Davis R, Banerjee A, Gill P, Liew S, Chamas L, Hernandez J, Mahtani K, Hayward G, Harrison S, Lasserson D, Mickan S, Sellers C, Carnes D, Homer K, Steed L, Ross J, Denny N, Goyder C, Thompson M, Ward A. Evidence for non-communicable diseases: analysis of Cochrane reviews and randomised trials by World Bank classification. BMJ Open 2013; 3:bmjopen-2013-003298. [PMID: 23833146 PMCID: PMC3703573 DOI: 10.1136/bmjopen-2013-003298] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Prevalence of non-communicable diseases (NCDs) is increasing globally, with the greatest projected increases in low-income and middle-income countries. We sought to quantify the proportion of Cochrane evidence relating to NCDs derived from such countries. METHODS We searched the Cochrane database of systematic reviews for reviews relating to NCDs highlighted in the WHO NCD action plan (cardiovascular, cancers, diabetes and chronic respiratory diseases). We excluded reviews at the protocol stage and those that were repeated or had been withdrawn. For each review, two independent researchers extracted data relating to the country of the corresponding author and the number of trials and participants from countries, using the World Bank classification of gross national income per capita. RESULTS 797 reviews were analysed, with a reported total number of 12 340 trials and 10 937 306 participants. Of the corresponding authors 90% were from high-income countries (41% from the UK). Of the 746 reviews in which at least one trial had met the inclusion criteria, only 55% provided a summary of the country of included trials. Analysis of the 633 reviews in which country of trials could be established revealed that almost 90% of trials and over 80% of participants were from high-income countries. 438 (5%) trials including 1 145 013 (11.7%) participants were undertaken in low-middle income countries. We found that only 13 (0.15%) trials with 982 (0.01%) participants were undertaken in low-income countries. Other than the five Cochrane NCD corresponding authors from South Africa, only one other corresponding author was from Africa (Gambia). DISCUSSION The overwhelming body of evidence for NCDs pertains to high-income countries, with only a small number of review authors based in low-income settings. As a consequence, there is an urgent need for research infrastructure and funding for the undertaking of high-quality trials in this area.
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Affiliation(s)
- C Heneghan
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Burr JM, Botello-Pinzon P, Takwoingi Y, Hernández R, Vazquez-Montes M, Elders A, Asaoka R, Banister K, van der Schoot J, Fraser C, King A, Lemij H, Sanders R, Vernon S, Tuulonen A, Kotecha A, Glasziou P, Garway-Heath D, Crabb D, Vale L, Azuara-Blanco A, Perera R, Ryan M, Deeks J, Cook J. Surveillance for ocular hypertension: an evidence synthesis and economic evaluation. Health Technol Assess 2012; 16:1-271, iii-iv. [PMID: 22687263 DOI: 10.3310/hta16290] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways. DESIGN A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model. SETTING Primary and secondary care. PARTICIPANTS Adults with ocular hypertension (IOP > 21 mmHg) and the public (surveillance preferences). INTERVENTIONS We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, 'NICE intensive' (4-monthly to annual monitoring) and 'NICE conservative' (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a 'treat all' pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community. MAIN OUTCOME MEASURES Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs). RESULTS The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. 'Treat all' was the least costly and 'NICE intensive' the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a 'treat all' pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The 'NICE intensive' pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence. LIMITATIONS Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates. CONCLUSIONS For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment. FUNDING The National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- J M Burr
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Stevens RJ, Ali R, Bankhead CR, Bethel MA, Cairns BJ, Camisasca RP, Crowe FL, Farmer AJ, Harrison S, Hirst JA, Home P, Kahn SE, McLellan JH, Perera R, Plüddemann A, Ramachandran A, Roberts NW, Rose PW, Schweizer A, Viberti G, Holman RR. Cancer outcomes and all-cause mortality in adults allocated to metformin: systematic review and collaborative meta-analysis of randomised clinical trials. Diabetologia 2012; 55:2593-2603. [PMID: 22875195 DOI: 10.1007/s00125-012-2653-7] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/12/2012] [Indexed: 12/31/2022]
Abstract
AIMS/HYPOTHESIS Observational studies suggest that metformin may reduce cancer risk by approximately one-third. We examined cancer outcomes and all-cause mortality in published randomised controlled trials (RCTs). METHODS RCTs comparing metformin with active glucose-lowering therapy or placebo/usual care, with minimum 500 participants and 1-year follow-up, were identified by systematic review. Data on cancer incidence and all-cause mortality were obtained from publications or by contacting investigators. For two trials, cancer incidence data were not available; cancer mortality was used as a surrogate. Summary RRs, 95% CIs and I (2)statistics for heterogeneity were calculated by fixed effects meta-analysis. RESULTS Of 4,039 abstracts identified, 94 publications described 14 eligible studies. RRs for cancer were available from 11 RCTs with 398 cancers during 51,681 person-years. RRs for all-cause mortality were available from 13 RCTs with 552 deaths during 66,447 person-years. Summary RRs for cancer outcomes in people randomised to metformin compared with any comparator were 1.02 (95% CI 0.82, 1.26) across all trials, 0.98 (95% CI 0.77, 1.23) in a subgroup analysis of active-comparator trials and 1.36 (95% CI 0.74, 2.49) in a subgroup analysis of placebo/usual care comparator trials. The summary RR for all-cause mortality was 0.94 (95% CI 0.79, 1.12) across all trials. CONCLUSIONS/INTERPRETATION Meta-analysis of currently available RCT data does not support the hypothesis that metformin lowers cancer risk by one-third. Eligible trials also showed no significant effect of metformin on all-cause mortality. However, limitations include heterogeneous comparator types, absent cancer data from two trials, and short follow-up, especially for mortality.
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Affiliation(s)
- R J Stevens
- Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK.
| | - R Ali
- Cancer Epidemiology Unit, University of Oxford, Oxford, UK
| | - C R Bankhead
- Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - M A Bethel
- Diabetes Trials Unit, Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - B J Cairns
- Cancer Epidemiology Unit, University of Oxford, Oxford, UK
| | - R P Camisasca
- TGRD Europe, Takeda Pharmaceutical Company, London, UK
| | - F L Crowe
- Cancer Epidemiology Unit, University of Oxford, Oxford, UK
| | - A J Farmer
- Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - S Harrison
- Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - J A Hirst
- Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - P Home
- ICM-Diabetes, The Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - S E Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA, USA
| | - J H McLellan
- Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - R Perera
- Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - A Plüddemann
- Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - A Ramachandran
- India Diabetes Research Foundation, Dr A. Ramachandran's Diabetes Hospitals, Egmore, Chennai, India
| | - N W Roberts
- Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - P W Rose
- Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | | | - G Viberti
- Unit for Metabolic Medicine, School of Medicine, King's College London, London, UK
| | - R R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, Oxford, UK
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Perera R, Ekanayake L. Oral impacts and their association with tooth loss in Sri Lankan adults. Community Dent Health 2012; 29:214-218. [PMID: 23038937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To determine the prevalence of oral impacts and the association between tooth loss and oral impacts in Sri Lankan adults. BASIC RESEARCH DESIGN A cross-sectional study where the data were collected by means of a pre-tested interviewer administered questionnaire and an oral examination. PARTICIPANTS 916 > or = 40 year olds from the Colombo district. MAIN OUTCOME MEASURES Oral impacts were assessed using a validated Sinhalese translation of the Oral Health Impact Profile-14. RESULTS The prevalence of oral impacts was 27%. The most commonly reported impacts were in the domain of physical pain: "pain" and "uncomfortable to eat". Of the 14 oral impacts, tooth loss was associated with only 6 impacts. According to the multiple logistic regression analysis, the prevalence of oral impacts was independently associated with the number of missing teeth, missing anterior teeth and the number of natural occluding premolar pairs. CONCLUSIONS The number of missing teeth and the position of teeth were associated with the reporting of oral impacts in this sample of adults. As the position of missing teeth was related to oral impacts, it could be concluded that all missing teeth do not have the same adverse effect on the physical and psychosocial well-being of the subjects.
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Affiliation(s)
- R Perera
- Dental Institute, Colombo, Sri Lanka
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Nijman RG, Thompson M, van Veen M, Perera R, Moll HA, Oostenbrink R. Derivation and validation of age and temperature specific reference values and centile charts to predict lower respiratory tract infection in children with fever: prospective observational study. BMJ 2012; 345:e4224. [PMID: 22761088 PMCID: PMC3388747 DOI: 10.1136/bmj.e4224] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To develop reference values and centile charts for respiratory rate based on age and body temperature, and to determine how well these reference values can predict the presence of lower respiratory tract infections (LRTI) in children with fever. DESIGN Prospective observational study. PARTICIPANTS Febrile children aged at least 1 month to just under 16 years (derivation population, n = 1555; validation population, n = 671) selected from patients attending paediatric emergency departments or assessment units in hospitals. SETTING One hospital in the Netherlands in 2006 and 2008 (derivation population); one hospital in the Netherlands in 2003-05 and one hospital in the United Kingdom in 2005-06 (validation population). INTERVENTION We used the derivation population to produce respiratory rate centile charts, and calculated 50th, 75th, 90th, and 97th centiles of respiratory rate at a specific body temperature. Multivariable regression analysis explored associations between respiratory rate, age, and temperature; results were validated in the validation population by calculating diagnostic performance measures, z scores, and corresponding centiles of children with diagnoses of pneumonic LRTI (as confirmed by chest radiograph), non-pneumonic LRTI, and non-LRTI. MAIN OUTCOME MEASURE Age, respiratory rate (breaths/min) and body temperature (°C), presence of LRTI. RESULTS Respiratory rate increased overall by 2.2 breaths/min per 1°C rise (standard error 0.2) after accounting for age and temperature in the model. We observed no interactions between age, temperature, and respiratory rates. Age and temperature dependent cut-off values at the 97th centile were more useful for ruling in LRTI (specificity 0.94 (95% confidence interval 0.92 to 0.96), positive likelihood ratio 3.66 (2.34 to 5.73)) than existing respiratory rate thresholds such as Advanced Pediatrics Life Support values (0.53 (0.48 to 0.57), 1.59 (1.41 to 1.80)). However, centile cut-offs could not discriminate between pneumonic LRTI and non-pneumonic LRTI. CONCLUSIONS Age specific and temperature dependent centile charts describe new reference values for respiratory rate in children with fever. Cut-off values at the 97th centile were more useful in detecting the presence of LRTI than existing respiratory rate thresholds.
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Affiliation(s)
- R G Nijman
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, 3015 GJ Rotterdam, Netherlands
| | - M Thompson
- Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - M van Veen
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, 3015 GJ Rotterdam, Netherlands
| | - R Perera
- Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - H A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, 3015 GJ Rotterdam, Netherlands
| | - R Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, 3015 GJ Rotterdam, Netherlands
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Shinkins B, Stevens R, Perera R. ‘Optimum threshold estimation based on cost function in a multistate diagnostic setting’ by K. Skaltsa, L. Jover, D. Fuster and J. L. Carrasco. Stat Med 2012; 31:1110-2. [DOI: 10.1002/sim.4483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- B. Shinkins
- Department of Primary Care Health Sciences; University of Oxford
| | - R. Stevens
- Department of Primary Care Health Sciences; University of Oxford
| | - R. Perera
- Department of Primary Care Health Sciences; University of Oxford
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Arteaga A, Alzate A, De Diego A, Cisneros D, Perera R. Refuerzo externo a cortante con láminas de CFRP en elementos de hormigón armado. ACTA ACUST UNITED AC 2012. [DOI: 10.3989/mc.2012.06611] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nuñez K, Rosales C, Perera R, Villarreal N, Pastor J. Poly(lactic acid)/low-density polyethylene blends and its nanocomposites based on sepiolite. POLYM ENG SCI 2011. [DOI: 10.1002/pen.22168] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Perera R, Albano C, Sánchez Y, Karam A, Silva P, Pastor JM. Changes in structural characteristics of LLDPE functionalized with DEM using gamma-irradiation. J Appl Polym Sci 2011. [DOI: 10.1002/app.35125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [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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