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Pirani T, Wilson A, Brealey D, Low R, O'Neill S, Le J, Jhanji S, Bangash MN, Mathew A, Wright C, Latif AL, Irvine D, Kasipandian V, Singh N, Saha R, Metaxa V. Critical care utilisation for patients receiving chimeric antigen receptor (CAR) T cell therapy in the UK. Br J Anaesth 2024; 132:1004-1006. [PMID: 38521658 DOI: 10.1016/j.bja.2024.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 03/25/2024] Open
Affiliation(s)
- Tasneem Pirani
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Anthony Wilson
- Department of Critical Care and Anaesthesia, Manchester Royal Infirmary, Manchester, UK
| | - David Brealey
- Critical Care Department, University College London Hospital NHS Foundation Trust, London, UK
| | - Ryan Low
- Division of Clinical Haematology, University College London Hospitals, London, UK
| | - Suzanne O'Neill
- Department of Critical Care and Anaesthesia, Freeman Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Jenny Le
- Haematology Department, University Hospital Bristol and Weston, Bristol, UK
| | - Shaman Jhanji
- Critical Care Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - Mansoor N Bangash
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Amrith Mathew
- Haematology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Christopher Wright
- Department of Intensive Care, Greater Glasgow and Clyde NHS Foundation Trust, Glasgow, UK
| | - Anne-Louise Latif
- Haematology Department, Greater Glasgow and Clyde NHS Foundation Trust, Glasgow, UK
| | - David Irvine
- Haematology Department, Greater Glasgow and Clyde NHS Foundation Trust, Glasgow, UK
| | - Vidya Kasipandian
- Critical Care Department, The Christie NHS Foundation Trust, Manchester, UK
| | - Neeraj Singh
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Rohit Saha
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK.
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2
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Janssen H, Jhanji S, Oliver NS, Ackland GL. Ward monitoring 4.0: real-time metabolic insights from continuous glucose monitoring into perioperative organ dysfunction. Br J Anaesth 2024; 132:843-848. [PMID: 38448275 DOI: 10.1016/j.bja.2024.01.039] [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: 12/18/2023] [Revised: 01/08/2024] [Accepted: 01/27/2024] [Indexed: 03/08/2024] Open
Abstract
The now-routine clinical deployment of continuous glucose monitoring has demonstrated benefit in real-world settings. We make the case that continuous glucose monitoring can help re-examine, at scale, the role that (stress) hyperglycaemia plays in fuelling organ dysfunction after tissue trauma. Provided robust perioperative data do emerge, well-established continuous glucose monitoring technology could soon help transform the perioperative landscape.
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Affiliation(s)
- Henrike Janssen
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Shaman Jhanji
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Nick S Oliver
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
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Dowling EJ, Simons LE, Crum AJ, Spunt SL, Simon P, Webster SN, Brown MRD, Jhanji S, Chilcot J, Heathcote LC. Body Mindsets are Associated With Pain and Threat-Related Risk Factors for Pain in Survivors of Childhood Cancer. J Pain 2024; 25:165-175. [PMID: 37549774 DOI: 10.1016/j.jpain.2023.07.030] [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] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/28/2023] [Accepted: 07/29/2023] [Indexed: 08/09/2023]
Abstract
Pain is a common consequence of childhood cancer. While most research has examined biomedical predictors of post-cancer pain, biopsychosocial conceptualisations such as the cancer threat interpretation (CTI) model hold promise for guiding comprehensive pain management strategies. Guided by the CTI model, this cross-sectional study evaluated correlates of post-cancer pain in childhood cancer survivors including threat-related risk factors (bodily threat monitoring, fear of cancer recurrence, help-seeking) and mindsets about the body. In the preceding three months, 21.8% of the survivors reported chronic pain (>3 months), and 14.3% experienced pain most days. Greater bodily threat monitoring, more fear of cancer recurrence, and more help-seeking were associated with more pain. There was heterogeneity in the mindsets that survivors of childhood cancer hold about their bodies. Holding the mindset that the 'body is an adversary' was associated with more pain, greater bodily threat monitoring, and more fear of cancer recurrence. Holding the mindset that the 'body is responsive' was associated with less bodily threat monitoring, while the mindset that the 'body is capable' was associated with greater help-seeking. A path model demonstrated a significant combined indirect effect of the 'body is an adversary' mindset on pain through bodily threat monitoring and fear of cancer recurrence. Overall, this study supported that a sub-group of childhood cancer survivors experience persistent and interfering pain and provided cross-sectional support for threat-related correlates for pain aligning with the CTI model. Body mindsets were associated with pain and threat-related correlates and may represent a novel target to support survivors with pain. PERSPECTIVE: This article presents associations of body mindsets, threat-related risk factors, and pain in survivors of childhood cancer (aged 11-25), guided by the Cancer Threat Interpretation model. The study indicates that body mindsets may be novel targets to embed in comprehensive post-cancer pain management approaches to support young survivors with pain.
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Affiliation(s)
- Emily J Dowling
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Laura E Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Alia J Crum
- Department of Psychology, Stanford University, Stanford, California
| | - Sheri L Spunt
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Pamela Simon
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sarah N Webster
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Matthew R D Brown
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, United Kingdom; Pain Management Team, The Royal Marsden Hospital, The Institute of Cancer Research, London, United Kingdom
| | - Shaman Jhanji
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, United Kingdom; Pain Management Team, The Royal Marsden Hospital, The Institute of Cancer Research, London, United Kingdom
| | - Joseph Chilcot
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Lauren C Heathcote
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
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4
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Nelmes E, Edwards L, Jhanji S, Antcliffe DB, Tatham KC. Patients with cancer and sepsis trials: an unfair representation? Clin Med (Lond) 2023; 23:635-636. [PMID: 38052465 PMCID: PMC11046631 DOI: 10.7861/clinmed.2023-0408] [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] [Indexed: 12/07/2023]
Abstract
Approximately 20% of sepsis cases are thought to occur in patients with cancer. Thus, such patients are an important cohort to be represented and characterised among sepsis trials. However, patients with cancer are commonly excluded from sepsis trials, although the extent to which is unknown. In this opinion article, we discuss our findings that suggest that patients with cancer are being under-represented in sepsis trials, often with an unclear rationale. We question the validity of generalising results from sepsis trials to heterogenous cancer populations and call for wider inclusion of patients with cancer to bridge this knowledge gap in sepsis management.
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Affiliation(s)
| | | | | | | | - Kate C Tatham
- Imperial College London, London, UK and Consultant in Critical Care and Anaesthesia, Royal Marsden NHS Foundation Trust, London, UK
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5
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James A, Bruce D, Tetlow N, Patel AB, Black E, Whitehead N, Ratcliff A, Jamie Humphreys A, MacDonald N, McDonnell G, Raobaikady R, Thirugnanasambanthar J, Ravindran JI, Whitehead N, Minto G, Abbott TE, Jhanji S, Milliken D, Ackland GL. Heart rate recovery after orthostatic challenge and cardiopulmonary exercise testing in older individuals: prospective multicentre observational cohort study. BJA Open 2023; 8:100238. [PMID: 38026081 PMCID: PMC10654531 DOI: 10.1016/j.bjao.2023.100238] [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] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 09/12/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023]
Abstract
Background Impaired vagal function in older individuals, quantified by the 'gold standard' delayed heart rate recovery after maximal exercise (HRRexercise), is an independent predictor of cardiorespiratory capacity and mortality (particularly when HRR ≤12 beats min-1). Heart rate also often declines after orthostatic challenge (HRRorthostatic), but the mechanism remains unclear. We tested whether HRRorthostatic reflects similar vagal autonomic characteristics as HRRexercise. Methods Prospective multicentre cohort study of subjects scheduled for cardiopulmonary exercise testing (CPET) as part of routine care. Before undergoing CPET, heart rate was measured with participants seated for 3 min, before standing for 3 min (HRRorthostatic). HRRexercise 1 min after the end of CPET was recorded. The primary outcome was the correlation between mean heart rate change every 10 s for 1 min after peak heart rate was attained on standing and after exercise for each participant. Secondary outcomes were HRRorthostatic and peak VO2 compared between individuals with HRRexercise <12 beats min-1. Results A total of 87 participants (mean age: 64 yr [95%CI: 61-66]; 48 (55%) females) completed both tests. Mean heart rate change every 10 s for 1 min after peak heart rate after standing and exercise was significantly correlated (R2=0.81; P<0.0001). HRRorthostatic was unchanged in individuals with HRRexercise ≤12 beats min-1 (n=27), but was lower when HRRexercise >12 beats min-1 (n=60; mean difference: 3 beats min-1 [95% confidence interval 1-5 beats min-1]; P<0.0001). Slower HRRorthostatic was associated with lower peak VO2 (mean difference: 3.7 ml kg-1 min-1 [95% confidence interval 0.7-6.8 ml kg-1 min-1]; P=0.039). Conclusion Prognostically significant heart rate recovery after exhaustive exercise is characterised by quantitative differences in heart rate recovery after orthostatic challenge. These data suggest that orthostatic challenge is a valid, simple test indicating vagal impairment. Clinical trial registration researchregistry6550.
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Affiliation(s)
- Aaron James
- Department of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - David Bruce
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Nicholas Tetlow
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Amour B.U. Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary, University of London, UK
| | - Ethel Black
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Nicole Whitehead
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Anna Ratcliff
- Department of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Neil MacDonald
- Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, London, UK
| | - Gayle McDonnell
- Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, London, UK
| | - Ravishankar Raobaikady
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary, University of London, UK
| | | | - Jeuela I. Ravindran
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary, University of London, UK
| | - Nicole Whitehead
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Gary Minto
- Department of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Tom E.F. Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary, University of London, UK
- Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, London, UK
| | - Shaman Jhanji
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Don Milliken
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Gareth L. Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary, University of London, UK
- Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, London, UK
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6
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Wu MY, Shepherd STC, Fendler A, Carr EJ, Au L, Harvey R, Dowgier G, Hobbs A, Herman LS, Ragno M, Adams L, Schmitt AM, Tippu Z, Shum B, Farag S, Rogiers A, O'Reilly N, Bawumia P, Smith C, Carlyle E, Edmonds K, Del Rosario L, Lingard K, Mangwende M, Holt L, Ahmod H, Korteweg J, Foley T, Barber T, Hepworth S, Emslie-Henry A, Caulfield-Lynch N, Byrne F, Deng D, Williams B, Brown M, Caidan S, Gavrielides M, MacRae JI, Kelly G, Peat K, Kelly D, Murra A, Kelly K, O'Flaherty M, Popat S, Yousaf N, Jhanji S, Tatham K, Cunningham D, Van As N, Young K, Furness AJS, Pickering L, Beale R, Swanton C, Gandhi S, Gamblin S, Bauer DLV, Kassiotis G, Howell M, Walker S, Nicholson E, Larkin J, Wall EC, Turajlic S. Sotrovimab restores neutralization against current Omicron subvariants in patients with blood cancer. Cancer Cell 2023; 41:821-823. [PMID: 37116490 PMCID: PMC10113515 DOI: 10.1016/j.ccell.2023.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 04/30/2023]
Abstract
Wu et al. report that patients with hematologic malignancies have reduced immunity against SARS-CoV-2 Omicron subvariants and Sotrovimab retains neutralizing capacity against all tested Omicron subvariants.
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Affiliation(s)
- Mary Y Wu
- COVID Surveillance Unit, The Francis Crick Institute, London NW1 1AT, UK
| | - Scott T C Shepherd
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London SW7 3RP, UK
| | - Annika Fendler
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Department of Urology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Edward J Carr
- Cell Biology of Infection Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Division of Medicine, University College London, London NW1 2PG, UK
| | - Lewis Au
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London SW7 3RP, UK; Department of Medical Oncology, Peter MacCallum Cancer Centre, VIC 3010, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, VIC 3010, Melbourne, Australia
| | - Ruth Harvey
- Worldwide Influenza Centre, The Francis Crick Institute, London NW1 1AT, UK
| | - Giulia Dowgier
- COVID Surveillance Unit, The Francis Crick Institute, London NW1 1AT, UK
| | - Agnieszka Hobbs
- COVID Surveillance Unit, The Francis Crick Institute, London NW1 1AT, UK
| | - Lou S Herman
- COVID Surveillance Unit, The Francis Crick Institute, London NW1 1AT, UK
| | - Martina Ragno
- COVID Surveillance Unit, The Francis Crick Institute, London NW1 1AT, UK
| | - Lorin Adams
- Worldwide Influenza Centre, The Francis Crick Institute, London NW1 1AT, UK
| | - Andreas M Schmitt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Zayd Tippu
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London SW7 3RP, UK
| | - Benjamin Shum
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London SW7 3RP, UK
| | - Sheima Farag
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Aljosja Rogiers
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Nicola O'Reilly
- Worldwide Influenza Centre, The Francis Crick Institute, London NW1 1AT, UK
| | - Philip Bawumia
- Human Biology Science and Technology Platform, The Francis Crick Institute, London NW1 1AT, UK
| | - Callie Smith
- Human Biology Science and Technology Platform, The Francis Crick Institute, London NW1 1AT, UK
| | - Eleanor Carlyle
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Kim Edmonds
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Lyra Del Rosario
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Karla Lingard
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Mary Mangwende
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Lucy Holt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Hamid Ahmod
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Justine Korteweg
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Tara Foley
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Taja Barber
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Stephanie Hepworth
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | | | | | - Fiona Byrne
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Daqi Deng
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Bryan Williams
- School of Life and Medical Sciences, University College London, 235 Euston Road, London NW1 2BU, UK; University College London Hospitals NHS Foundation Trust Biomedical Research Centre, London WC1E 6BT, UK
| | - Michael Brown
- University College London Hospitals NHS Foundation Trust Biomedical Research Centre, London WC1E 6BT, UK; Clinical Research Department, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Simon Caidan
- Safety, Health & Sustainability, The Francis Crick Institute, London NW1 1AT, UK
| | - Mike Gavrielides
- Scientific Computing Scientific Technology Platform, The Francis Crick Institute, London NW1 1AT, UK
| | - James I MacRae
- Metabolomics Scientific Technology Platform, The Francis Crick Institute, London NW1 1AT, UK
| | - Gavin Kelly
- Department of Bioinformatics and Biostatistics, The Francis Crick Institute, London, UK
| | - Kema Peat
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Denise Kelly
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Aida Murra
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Kayleigh Kelly
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Molly O'Flaherty
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Sanjay Popat
- Lung Unit, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Nadia Yousaf
- Lung Unit, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Shaman Jhanji
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Kate Tatham
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - David Cunningham
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, SM2 5PT, UK
| | - Nicholas Van As
- Clincal Oncology Unit, The Royal Marsden NHS Foundation Trust, London NW1 1AT, UK
| | - Kate Young
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Andrew J S Furness
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London SW7 3RP, UK
| | - Lisa Pickering
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Rupert Beale
- Cell Biology of Infection Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Division of Medicine, University College London, London NW1 2PG, UK
| | - Charles Swanton
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London NW1 1AT, UK; University College London Cancer Institute, London WC1E 6DD, UK
| | - Sonia Gandhi
- Neurodegeneration Biology Laboratory, The Francis Crick Institute, London NW1 1AT, UK; UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Steve Gamblin
- Structural Biology of Disease Processes Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - David L V Bauer
- RNA Virus Replication Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - George Kassiotis
- Retroviral Immunology Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Michael Howell
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Susanna Walker
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Emma Nicholson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Haemato-oncology Unit, The Institute of Cancer Research, London SW7 3RP, UK
| | - James Larkin
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London SW7 3RP, UK
| | - Emma C Wall
- School of Life and Medical Sciences, University College London, 235 Euston Road, London NW1 2BU, UK; The Francis Crick Institute, London NW1 1AT, UK.
| | - Samra Turajlic
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London SW7 3RP, UK.
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7
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Tabah A, Buetti N, Staiquly Q, Ruckly S, Akova M, Aslan AT, Leone M, Conway Morris A, Bassetti M, Arvaniti K, Lipman J, Ferrer R, Qiu H, Paiva JA, Povoa P, De Bus L, De Waele J, Zand F, Gurjar M, Alsisi A, Abidi K, Bracht H, Hayashi Y, Jeon K, Elhadi M, Barbier F, Timsit JF, Pollock H, Margetts B, Young M, Bhadange N, Tyler S, Ledtischke A, Finnis M, Ledtischke A, Finnis M, Dwivedi J, Saxena M, Biradar V, Soar N, Sarode V, Brewster D, Regli A, Weeda E, Ahmed S, Fourie C, Laupland K, Ramanan M, Walsham J, Meyer J, Litton E, Palermo AM, Yap T, Eroglu E, Attokaran AG, Jaramillo C, Nafees KMK, Rashid NAHA, Walid HAMI, Mon T, Moorthi PD, Sudhirchandra S, Sridharan DD, Haibo Q, Jianfeng X, Wei-Hua L, Zhen W, Qian C, Luo J, Chen X, Wang H, Zhao P, Zhao J, Wusi Q, Mingmin C, Xu L, Yin C, Wang R, Wang J, Yin Y, Zhang M, Ye J, Hu C, Zhou S, Huang M, Yan J, Wang Y, Qin B, Ye L, Weifeng X, Peije L, Geng N, Hayashi Y, Karumai T, Yamasaki M, Hashimoto S, Hosokawa K, Makino J, Matsuyoshi T, Kuriyama A, Shigemitsu H, Mishima Y, Nagashima M, Yoshida H, Fujitani S, Omori K, Rinka H, Saito H, Atobe K, Kato H, Takaki S, Hasan MS, Jamaluddin MFH, Pheng LS, Visvalingam S, Liew MT, Wong SLD, Fong KK, Rahman HBA, Noor ZM, Tong LK, Azman AH, Mazlan MZ, Ali S, Jeon K, Lee SM, Park S, Park SY, Lim SY, Goh QY, Ng SY, Lie SA, Kwa ALH, Goh KJ, Li AY, Ong CYM, Lim JY, Quah JL, Ng K, Ng LXL, Yeh YC, Chou NK, Cia CT, Hu TY, Kuo LK, Ku SC, Wongsurakiat P, Apichatbutr Y, Chiewroongroj S, Nadeem R, Houfi AE, Alsisi A, Elhadidy A, Barsoum M, Osman N, Mostafa T, Elbahnasawy M, Saber A, Aldhalia A, Elmandouh O, Elsayed A, Elbadawy MA, Awad AK, Hemead HM, Zand F, Ouhadian M, Borsi SH, Mehraban Z, Kashipazha D, Ahmadi F, Savaie M, Soltani F, Rashidi M, Baghbanian R, Javaherforoosh F, Amiri F, Kiani A, Zargar MA, Mahmoodpoor A, Aalinezhad F, Dabiri G, Sabetian G, Sarshad H, Masjedi M, Tajvidi R, Tabatabaei SMN, Ahmed AK, Singer P, Kagan I, Rigler M, Belman D, Levin P, Harara B, Diab A, Abilama F, Ibrahim R, Fares A, Buimsaedah A, Gamra M, Aqeelah A, AliAli AM, Homaidan AGS, Almiqlash B, Bilkhayr H, Bouhuwaish A, Taher AS, Abdulwahed E, Abousnina FA, Hdada AK, Jobran R, Hasan HB, Hasan RSB, Serghini I, Seddiki R, Boukatta B, Kanjaa N, Mouhssine D, Wajdi MA, Dendane T, Zeggwagh AA, Housni B, Younes O, Hachimi A, Ghannam A, Belkhadir Z, Amro S, Jayyab MA, Hssain AA, Elbuzidi A, Karic E, Lance M, Nissar S, Sallam H, Elrabi O, Almekhlafi GA, Awad M, Aljabbary A, Chaaban MK, Abu-Sayf N, Al-Jadaan M, Bakr L, Bouaziz M, Turki O, Sellami W, Centeno P, Morvillo LN, Acevedo JO, Lopez PM, Fernández R, Segura M, Aparicio DM, Alonzo MI, Nuccetelli Y, Montefiore P, Reyes LF, Reyes LF, Ñamendys-Silva SA, Romero-Gonzalez JP, Hermosillo M, Castillo RA, Leal JNP, Aguilar CG, Herrera MOG, Villafuerte MVE, Lomeli-Teran M, Dominguez-Cherit JG, Davalos-Alvarez A, Ñamendys-Silva SA, Sánchez-Hurtado L, Tejeda-Huezo B, Perez-Nieto OR, Tomas ED, De Bus L, De Waele J, Hollevoet I, Denys W, Bourgeois M, Vanderhaeghen SFM, Mesland JB, Henin P, Haentjens L, Biston P, Noel C, Layos N, Misset B, De Schryver N, Serck N, Wittebole X, De Waele E, Opdenacker G, Kovacevic P, Zlojutro B, Custovic A, Filipovic-Grcic I, Radonic R, Brajkovic AV, Persec J, Sakan S, Nikolic M, Lasic H, Leone M, Arbelot C, Timsit JF, Patrier J, Zappela N, Montravers P, Dulac T, Castanera J, Auchabie J, Le Meur A, Marchalot A, Beuzelin M, Massri A, Guesdon C, Escudier E, Mateu P, Rosman J, Leroy O, Alfandari S, Nica A, Souweine B, Coupez E, Duburcq T, Kipnis E, Bortolotti P, Le Souhaitier M, Mira JP, Garcon P, Duprey M, Thyrault M, Paulet R, Philippart F, Tran M, Bruel C, Weiss E, Janny S, Foucrier A, Perrigault PF, Djanikian F, Barbier F, Gainnier M, Bourenne J, Louis G, Smonig R, Argaud L, Baudry T, Dessap AM, Razazi K, Kalfon P, Badre G, Larcher R, Lefrant JY, Roger C, Sarton B, Silva S, Demeret S, Le Guennec L, Siami S, Aparicio C, Voiriot G, Fartoukh M, Dahyot-Fizelier C, Imzi N, Klouche K, Bracht H, Hoheisen S, Bloos F, Thomas-Rueddel D, Petros S, Pasieka B, Dubler S, Schmidt K, Gottschalk A, Wempe C, Lepper P, Metz C, Viderman D, Ymbetzhanov Y, Mugazov M, Bazhykayeva Y, Kaligozhin Z, Babashev B, Merenkov Y, Temirov T, Arvaniti K, Smyrniotis D, Psallida V, Fildisis G, Soulountsi V, Kaimakamis E, Iasonidou C, Papoti S, Renta F, Vasileiou M, Romanou V, Koutsoukou V, Matei MK, Moldovan L, Karaiskos I, Paskalis H, Marmanidou K, Papanikolaou M, Kampolis C, Oikonomou M, Kogkopoulos E, Nikolaou C, Sakkalis A, Chatzis M, Georgopoulou M, Efthymiou A, Chantziara V, Sakagianni A, Athanasa Z, Papageorgiou E, Ali F, Dimopoulos G, Almiroudi MP, Malliotakis P, Marouli D, Theodorou V, Retselas I, Kouroulas V, Papathanakos G, Montrucchio G, Sales G, De Pascale G, Montini LM, Carelli S, Vargas J, Di Gravio V, Giacobbe DR, Gratarola A, Porcile E, Mirabella M, Daroui I, Lodi G, Zuccaro F, Schlevenin MG, Pelosi P, Battaglini D, Cortegiani A, Ippolito M, Bellina D, Di Guardo A, Pelagalli L, Covotta M, Rocco M, Fiorelli S, Cotoia A, Rizzo AC, Mikstacki A, Tamowicz B, Komorowska IK, Szczesniak A, Bojko J, Kotkowska A, Walczak-Wieteska P, Wasowska D, Nowakowski T, Broda H, Peichota M, Pietraszek-Grzywaczewska I, Martin-Loeches I, Bisanti A, Cartoze N, Pereira T, Guimarães N, Alves M, Marques AJP, Pinto AR, Krystopchuk A, Teresa A, de Figueiredo AMP, Botelho I, Duarte T, Costa V, Cunha RP, Molinos E, da Costa T, Ledo S, Queiró J, Pascoalinho D, Nunes C, Moura JP, Pereira É, Mendes AC, Valeanu L, Bubenek-Turconi S, Grintescu IM, Cobilinschi C, Filipescu DC, Predoi CE, Tomescu D, Popescu M, Marcu A, Grigoras I, Lungu O, Gritsan A, Anderzhanova A, Meleshkina Y, Magomedov M, Zubareva N, Tribulev M, Gaigolnik D, Eremenko A, Vistovskaya N, Chukina M, Belskiy V, Furman M, Rocca RF, Martinez M, Casares V, Vera P, Flores M, Amerigo JA, Arnillas MPG, Bermudez RM, Armestar F, Catalan B, Roig R, Raguer L, Quesada MD, Santos ED, Gomà G, Ubeda A, Salgado DM, Espina LF, Prieto EG, Asensio DM, Rodriguez DM, Maseda E, De La Rica AS, Ayestaran JI, Novo M, Blasco-Navalpotro MA, Gallego AO, Sjövall F, Spahic D, Svensson CJ, Haney M, Edin A, Åkerlund J, De Geer L, Prazak J, Jakob S, Pagani J, Abed-Maillard S, Akova M, Aslan AT, Timuroglu A, Kocagoz S, Kusoglu H, Mehtap S, Ceyhun S, Altintas ND, Talan L, Kayaaslan B, Kalem AK, Kurt I, Telli M, Ozturk B, Erol Ç, Demiray EKD, Çolak S, Akbas T, Gundogan K, Sari A, Agalar C, Çolak O, Baykam NN, Akdogan OO, Yilmaz M, Tunay B, Cakmak R, Saltoglu N, Karaali R, Koksal I, Aksoy F, Eroglu A, Saracoglu KT, Bilir Y, Guzeldag S, Ersoz G, Evik G, Sungurtekin H, Ozgen C, Erdoğan C, Gürbüz Y, Altin N, Bayindir Y, Ersoy Y, Goksu S, Akyol A, Batirel A, Aktas SC, Morris AC, Routledge M, Morris AC, Ercole A, Antcliffe D, Rojo R, Tizard K, Faulkner M, Cowton A, Kent M, Raj A, Zormpa A, Tinaslanidis G, Khade R, Torlinski T, Mulhi R, Goyal S, Bajaj M, Soltan M, Yonan A, Dolan R, Johnson A, Macfie C, Lennard J, Templeton M, Arias SS, Franke U, Hugill K, Angell H, Parcell BJ, Cobb K, Cole S, Smith T, Graham C, Cerman J, Keegan A, Ritzema J, Sanderson A, Roshdy A, Szakmany T, Baumer T, Longbottom R, Hall D, Tatham K, Loftus S, Husain A, Black E, Jhanji S, Baikady RR, Mcguigan P, Mckee R, Kannan S, Antrolikar S, Marsden N, Torre VD, Banach D, Zaki A, Jackson M, Chikungwa M, Attwood B, Patel J, Tilley RE, Humphreys MSK, Renaud PJ, Sokhan A, Burma Y, Sligl W, Baig N, McCoshen L, Kutsogiannis DJ, Sligl W, Thompson P, Hewer T, Rabbani R, Huq SMR, Hasan R, Islam MM, Gurjar M, Baronia A, Kothari N, Sharma A, Karmakar S, Sharma P, Nimbolkar J, Samdani P, Vaidyanathan R, Rubina NA, Jain N, Pahuja M, Singh R, Shekhar S, Muzaffar SN, Ozair A, Siddiqui SS, Bose P, Datta A, Rathod D, Patel M, Renuka MK, Baby SK, Dsilva C, Chandran J, Ghosh P, Mukherjee S, Sheshala K, Misra KC, Yakubu SY, Ugwu EM, Olatosi JO, Desalu I, Asiyanbi G, Oladimeji M, Idowu O, Adeola F, Mc Cree M, Karar AAA, Saidahmed E, Hamid HKS. Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study. Intensive Care Med 2023; 49:178-190. [PMID: 36764959 PMCID: PMC9916499 DOI: 10.1007/s00134-022-06944-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/23/2022] [Indexed: 02/12/2023]
Abstract
PURPOSE In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials. METHODS We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021. RESULTS 2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28. CONCLUSIONS HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Brisbane, Australia. .,Queensland Critical Care Research Network (QCCRN), Brisbane, QLD, Australia. .,Queensland University of Technology, Brisbane, QLD, Australia. .,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Niccolò Buetti
- Infection Control Program and WHO Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.,Université de Paris, INSERM, IAME UMR 1137, 75018, Paris, France
| | | | - Stéphane Ruckly
- Université de Paris, INSERM, IAME UMR 1137, 75018, Paris, France.,ICUREsearch, Biometry, 38600, Fontaine, France
| | - Murat Akova
- Department of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey
| | - Abdullah Tarik Aslan
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Unit, Hospital Nord, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.,Division of Immunology, Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge, Cb2 1QP, UK.,JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge, Hills Road, Cambridge, CB2 0QQ, UK
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Kostoula Arvaniti
- Intensive Care Unit, Papageorgiou University Affiliated Hospital, Thessaloníki, Greece
| | - Jeffrey Lipman
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Nimes University Hospital, University of Montpellier, Nimes, France.,Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Ricard Ferrer
- Intensive Care Department, SODIR-VHIR Research Group, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - José-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar Universitário Sao Joao, Porto, Portugal.,Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal.,Infection and Sepsis ID Group, Porto, Portugal
| | - Pedro Povoa
- NOVA Medical School, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark.,Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal
| | - Liesbet De Bus
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jan De Waele
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Farid Zand
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
| | - Adel Alsisi
- ICU Department, Prime Hospital, Dubai, United Arab Emirates.,Critical Care Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Khalid Abidi
- Medical ICU, Ibn Sina University Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Hendrik Bracht
- Central Interdisciplinary Emergency Medicine, University Hospital Ulm, Ulm, Germany
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda General Hospital, Kamogawa, Japan
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | - François Barbier
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de L'Hôpital, 45100, Orléans, France
| | - Jean-François Timsit
- Université Paris-Cité, INSERM, IAME UMR 1137, 75018, Paris, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 Omdurman maternity hospitalrue Henri Huchard, 75877, Paris Cedex, France
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8
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Fizza Haider S, Sloss R, Jhanji S, Nicholson E, Creagh-Brown B. Management of adult patients with haematological malignancies in critical care. Anaesthesia 2023. [PMID: 36658786 DOI: 10.1111/anae.15955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2022] [Indexed: 01/21/2023]
Abstract
There are a diverse range of haematological malignancies with varying clinical presentations and prognoses. Patients with haematological malignancy may require admission to critical care at the time of diagnosis or due to treatment related effects and complications. Although the prognosis for such patients requiring critical care has improved, there remain uncertainties in optimal clinical management. Identification of patients who will benefit from critical care admission is challenging and selective involvement of palliative care may help to reduce unnecessary and non-beneficial treatments. While patients with haematological malignancy can present a challenge to critical care physicians, good outcomes can be achieved. In this narrative review, we provide a brief overview of relevant haematological malignancies for the critical care physician and a summary of recent treatment advances. Subsequently, we focus on critical care management for the patient with haematological malignancy including sepsis; acute respiratory failure; prevention and treatment of tumour lysis syndrome; thrombocytopaenia; and venous thromboembolism. We also discuss immunotherapeutic-specific related complications and their management, including cytokine release syndrome and immune effector cell associated neurotoxicity syndrome associated with chimeric antigen receptor T-cell therapy. While the management of haematological malignancies is highly specialised and increasingly centralised, acutely unwell patients often present to their local hospital with complications requiring critical care expertise. The aim of this review is to provide a contemporary overview of disease and management principles for non-specialist critical care teams.
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Affiliation(s)
- S Fizza Haider
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - R Sloss
- Department of Peri-Operative Medicine (Critical Care), St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - S Jhanji
- Department of Critical Care, Royal Marsden Hospital, London, UK.,Division of Cancer Biology, Institute of Cancer Research, London, UK
| | - E Nicholson
- Department of Haematology, Royal Marsden Hospital, London, UK.,Division of Cancer Therapeutics, Institute of Cancer Research, London, UK
| | - B Creagh-Brown
- Intensive Care Unit, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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9
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Fendler A, Shepherd STC, Au L, Wu M, Harvey R, Wilkinson KA, Schmitt AM, Tippu Z, Shum B, Farag S, Rogiers A, Carlyle E, Edmonds K, Del Rosario L, Lingard K, Mangwende M, Holt L, Ahmod H, Korteweg J, Foley T, Barber T, Emslie-Henry A, Caulfield-Lynch N, Byrne F, Deng D, Kjaer S, Song OR, Queval CJ, Kavanagh C, Wall EC, Carr EJ, Caidan S, Gavrielides M, MacRae JI, Kelly G, Peat K, Kelly D, Murra A, Kelly K, O'Flaherty M, Shea RL, Gardner G, Murray D, Popat S, Yousaf N, Jhanji S, Tatham K, Cunningham D, Van As N, Young K, Furness AJS, Pickering L, Beale R, Swanton C, Gandhi S, Gamblin S, Bauer DLV, Kassiotis G, Howell M, Nicholson E, Walker S, Wilkinson RJ, Larkin J, Turajlic S. Functional immune responses against SARS-CoV-2 variants of concern after fourth COVID-19 vaccine dose or infection in patients with blood cancer. Cell Rep Med 2022; 3:100781. [PMID: 36240755 PMCID: PMC9513326 DOI: 10.1016/j.xcrm.2022.100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/07/2022] [Accepted: 09/21/2022] [Indexed: 11/28/2022]
Abstract
Patients with blood cancer continue to have a greater risk of inadequate immune responses following three COVID-19 vaccine doses and risk of severe COVID-19 disease. In the context of the CAPTURE study (NCT03226886), we report immune responses in 80 patients with blood cancer who received a fourth dose of BNT162b2. We measured neutralizing antibody titers (NAbTs) using a live virus microneutralization assay against wild-type (WT), Delta, and Omicron BA.1 and BA.2 and T cell responses against WT and Omicron BA.1 using an activation-induced marker (AIM) assay. The proportion of patients with detectable NAb titers and T cell responses after the fourth vaccine dose increased compared with that after the third vaccine dose. Patients who received B cell-depleting therapies within the 12 months before vaccination have the greatest risk of not having detectable NAbT. In addition, we report immune responses in 57 patients with breakthrough infections after vaccination.
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Affiliation(s)
- Annika Fendler
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Scott T C Shepherd
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Lewis Au
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Mary Wu
- COVID Surveillance Unit, The Francis Crick Institute, London NW1 1AT, UK
| | - Ruth Harvey
- Worldwide Influenza Centre, The Francis Crick Institute, London NW1 1AT, UK
| | - Katalin A Wilkinson
- Tuberculosis Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Wellcome Center for Infectious Disease Research in Africa, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Andreas M Schmitt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Zayd Tippu
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Benjamin Shum
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Sheima Farag
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Aljosja Rogiers
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Eleanor Carlyle
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Kim Edmonds
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Lyra Del Rosario
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Karla Lingard
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Mary Mangwende
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Lucy Holt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Hamid Ahmod
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Justine Korteweg
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Tara Foley
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Taja Barber
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | | | | | - Fiona Byrne
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Daqi Deng
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Svend Kjaer
- Structural Biology Scientific Technology Platform, The Francis Crick Institute, London NW1 1AT, UK
| | - Ok-Ryul Song
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Christophe J Queval
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Caitlin Kavanagh
- COVID Surveillance Unit, The Francis Crick Institute, London NW1 1AT, UK
| | - Emma C Wall
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK; University College London Hospitals NHS Foundation Trust Biomedical Research Centre, London WC1E 6BT, UK
| | - Edward J Carr
- Cell Biology of Infection Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Simon Caidan
- Safety, Health & Sustainability, The Francis Crick Institute, London NW1 1AT, UK
| | - Mike Gavrielides
- Scientific Computing Scientific Technology Platform, The Francis Crick Institute, London NW1 1AT, UK
| | - James I MacRae
- Metabolomics Scientific Technology Platform, The Francis Crick Institute, London NW1 1AT, UK
| | - Gavin Kelly
- Department of Bioinformatics and Biostatistics, The Francis Crick Institute, London, UK
| | - Kema Peat
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Denise Kelly
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Aida Murra
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Kayleigh Kelly
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Molly O'Flaherty
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Robyn L Shea
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London NW1 1AT, UK; Translational Cancer Biochemistry Laboratory, The Institute of Cancer Research, London SW7 3RP, UK
| | - Gail Gardner
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London NW1 1AT, UK
| | - Darren Murray
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London NW1 1AT, UK
| | - Sanjay Popat
- Lung Unit, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Nadia Yousaf
- Lung Unit, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Shaman Jhanji
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Kate Tatham
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - David Cunningham
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, Sutton SM2 5PT, UK
| | - Nicholas Van As
- Clincal Oncology Unit, The Royal Marsden NHS Foundation Trust, London NW1 1AT, UK
| | - Kate Young
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Andrew J S Furness
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Lisa Pickering
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Rupert Beale
- Cell Biology of Infection Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Division of Medicine, University College London, London NW1 2PG, UK
| | - Charles Swanton
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London NW1 1AT, UK; University College London Cancer Institute, London WC1E 6DD, UK
| | - Sonia Gandhi
- Neurodegeneration Biology Laboratory, The Francis Crick Institute, London NW1 1AT, UK; UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Steve Gamblin
- Structural Biology of Disease Processes Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - David L V Bauer
- RNA Virus Replication Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - George Kassiotis
- Retroviral Immunology Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Michael Howell
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Emma Nicholson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Haemato-oncology Unit, The Institute of Cancer Research, London SW7 3RP, UK
| | - Susanna Walker
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Robert J Wilkinson
- Tuberculosis Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Wellcome Center for Infectious Disease Research in Africa, University of Cape Town, Observatory 7925, Republic of South Africa; Department of Infectious Disease, Imperial College London, London W2 0NN, UK
| | - James Larkin
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London SW7 3RP, UK
| | - Samra Turajlic
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London SW7 3RP, UK.
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10
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Riedel B, Dubowitz J, Yeung J, Jhanji S, Kheterpal S, Avidan MS. On the horns of a dilemma: choosing total intravenous anaesthesia or volatile anaesthesia. Br J Anaesth 2022; 129:284-289. [PMID: 35835606 DOI: 10.1016/j.bja.2022.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 11/02/2022] Open
Abstract
There are two established techniques of delivering general anaesthesia: propofol-based total intravenous anaesthesia (TIVA) and volatile agent-based inhaled anaesthesia. Both techniques are offered as standard of care and have an established safety track record lasting more than 30 years. However, it is not currently known whether the choice of anaesthetic technique results in a fundamentally different patient experience or affects early, intermediate-term, and longer-term postoperative outcomes. This editorial comments on a recently published study that suggests that inhaled volatile anaesthesia might be associated with fewer postoperative surgical complications than propofol-based TIVA for patients undergoing colorectal cancer surgery. We consider the strengths and limitations of the study, place these findings in the context of the broader evidence, and discuss how the current controversies regarding anaesthetic technique can be resolved, thereby helping to bring precision medicine into the modern practice of perioperative care.
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Affiliation(s)
- Bernhard Riedel
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.
| | - Julia Dubowitz
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Joyce Yeung
- Department of Critical Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Shaman Jhanji
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK; Division of Cancer Biology, Institute of Cancer Research, London, UK
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, MO, USA
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11
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Fendler A, Shepherd STC, Au L, Wilkinson KA, Wu M, Schmitt AM, Tippu Z, Farag S, Rogiers A, Harvey R, Carlyle E, Edmonds K, Del Rosario L, Lingard K, Mangwende M, Holt L, Ahmod H, Korteweg J, Foley T, Barber T, Emslie-Henry A, Caulfield-Lynch N, Byrne F, Shum B, Gerard CL, Deng D, Kjaer S, Song OR, Queval C, Kavanagh C, Wall EC, Carr EJ, Namjou S, Caidan S, Gavrielides M, MacRae JI, Kelly G, Peat K, Kelly D, Murra A, Kelly K, O'Flaherty M, Shea RL, Gardner G, Murray D, Popat S, Yousaf N, Jhanji S, Van As N, Young K, Furness AJS, Pickering L, Beale R, Swanton C, Gandhi S, Gamblin S, Bauer DLV, Kassiotis G, Howell M, Nicholson E, Walker S, Wilkinson RJ, Larkin J, Turajlic S. Immune responses following third COVID-19 vaccination are reduced in patients with hematological malignancies compared to patients with solid cancer. Cancer Cell 2022; 40:438. [PMID: 35413273 PMCID: PMC8996376 DOI: 10.1016/j.ccell.2022.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Fendler A, Shepherd STC, Au L, Wu M, Harvey R, Schmitt AM, Tippu Z, Shum B, Farag S, Rogiers A, Carlyle E, Edmonds K, Del Rosario L, Lingard K, Mangwende M, Holt L, Ahmod H, Korteweg J, Foley T, Barber T, Emslie-Henry A, Caulfield-Lynch N, Byrne F, Deng D, Kjaer S, Song OR, Queval C, Kavanagh C, Wall EC, Carr EJ, Caidan S, Gavrielides M, MacRae JI, Kelly G, Peat K, Kelly D, Murra A, Kelly K, O'Flaherty M, Shea RL, Gardner G, Murray D, Yousaf N, Jhanji S, Tatham K, Cunningham D, Van As N, Young K, Furness AJS, Pickering L, Beale R, Swanton C, Gandhi S, Gamblin S, Bauer DLV, Kassiotis G, Howell M, Nicholson E, Walker S, Larkin J, Turajlic S. Omicron neutralising antibodies after third COVID-19 vaccine dose in patients with cancer. Lancet 2022; 399:905-907. [PMID: 35090602 PMCID: PMC8789238 DOI: 10.1016/s0140-6736(22)00147-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/15/2022] [Accepted: 01/23/2022] [Indexed: 12/16/2022]
Affiliation(s)
- Annika Fendler
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Scott T C Shepherd
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Lewis Au
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Mary Wu
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Ruth Harvey
- Worldwide Influenza Centre, The Francis Crick Institute, London NW1 1AT, UK
| | - Andreas M Schmitt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Zayd Tippu
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Benjamin Shum
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Sheima Farag
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Aljosja Rogiers
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Eleanor Carlyle
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Kim Edmonds
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Lyra Del Rosario
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Karla Lingard
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Mary Mangwende
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Lucy Holt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Hamid Ahmod
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Justine Korteweg
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Tara Foley
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Taja Barber
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | | | | | - Fiona Byrne
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Daqi Deng
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Svend Kjaer
- Structural Biology Scientific Technology Platform, The Francis Crick Institute, London NW1 1AT, UK
| | - Ok-Ryul Song
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Christophe Queval
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Caitlin Kavanagh
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Emma C Wall
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK; University College London Hospitals NHS Foundation Trust Biomedical Research Centre, London, UK
| | - Edward J Carr
- Cell Biology of Infection Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Simon Caidan
- Safety, Health & Sustainability, The Francis Crick Institute, London NW1 1AT, UK; University College London Cancer Institute, London, UK
| | - Mike Gavrielides
- Scientific Computing Scientific Technology Platform, The Francis Crick Institute, London NW1 1AT, UK
| | - James I MacRae
- Metabolomics Scientific Technology Platform, The Francis Crick Institute, London NW1 1AT, UK
| | - Gavin Kelly
- Department of Bioinformatics and Biostatistics, The Francis Crick Institute, London NW1 1AT, UK
| | - Kema Peat
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Denise Kelly
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Aida Murra
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Kayleigh Kelly
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Molly O'Flaherty
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Robyn L Shea
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, UK; Translational Cancer Biochemistry Laboratory, Institute of Cancer Research, London, UK
| | - Gail Gardner
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Darren Murray
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Nadia Yousaf
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, UK; Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, UK
| | - Shaman Jhanji
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - Kate Tatham
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - David Cunningham
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Nicholas Van As
- Clincal Oncology Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Kate Young
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Andrew J S Furness
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Lisa Pickering
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Rupert Beale
- Cell Biology of Infection Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Division of Medicine, University College London, London, UK
| | - Charles Swanton
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Sonia Gandhi
- Neurodegeneration Biology Laboratory, The Francis Crick Institute, London NW1 1AT, UK; UCL Queen Square Institute of Neurology, London, UK
| | - Steve Gamblin
- Structural Biology of Disease Processes Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - David L V Bauer
- RNA Virus Replication Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - George Kassiotis
- Retroviral Immunology Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Michael Howell
- High Throughput Screening Laboratory, The Francis Crick Institute, London NW1 1AT, UK
| | - Emma Nicholson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Susanna Walker
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - James Larkin
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Samra Turajlic
- Cancer Dynamics Laboratory, The Francis Crick Institute, London NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK; Melanoma and Kidney Cancer Team, Institute of Cancer Research, London, UK.
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13
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Fendler A, Shepherd STC, Au L, Wilkinson KA, Wu M, Schmitt AM, Tippu Z, Farag S, Rogiers A, Harvey R, Carlyle E, Edmonds K, Del Rosario L, Lingard K, Mangwende M, Holt L, Ahmod H, Korteweg J, Foley T, Barber T, Emslie-Henry A, Caulfield-Lynch N, Byrne F, Shum B, Gerard CL, Deng D, Kjaer S, Song OR, Queval C, Kavanagh C, Wall EC, Carr EJ, Namjou S, Caidan S, Gavrielides M, MacRae JI, Kelly G, Peat K, Kelly D, Murra A, Kelly K, O'Flaherty M, Shea RL, Gardner G, Murray D, Yousaf N, Jhanji S, Van As N, Young K, Furness AJS, Pickering L, Beale R, Swanton C, Gandhi S, Gamblin S, Bauer DLV, Kassiotis G, Howell M, Nicholson E, Walker S, Wilkinson RJ, Larkin J, Turajlic S. Immune responses following third COVID-19 vaccination are reduced in patients with hematological malignancies compared to patients with solid cancer. Cancer Cell 2022; 40:114-116. [PMID: 34968417 PMCID: PMC8716090 DOI: 10.1016/j.ccell.2021.12.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Annika Fendler
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Scott T C Shepherd
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lewis Au
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Katalin A Wilkinson
- Tuberculosis Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; Wellcome Center for Infectious Disease Research in Africa, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Mary Wu
- High Throughput Screening Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Andreas M Schmitt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Zayd Tippu
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Sheima Farag
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Aljosja Rogiers
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Ruth Harvey
- Worldwide Influenza Centre, The Francis Crick Institute, London, NW1 1AT, UK
| | - Eleanor Carlyle
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Kim Edmonds
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lyra Del Rosario
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Karla Lingard
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Mary Mangwende
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lucy Holt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Hamid Ahmod
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Justine Korteweg
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Tara Foley
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Taja Barber
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Andrea Emslie-Henry
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | | | - Fiona Byrne
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Benjamin Shum
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Camille L Gerard
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Daqi Deng
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Svend Kjaer
- Structural Biology STP, The Francis Crick Institute, London NW1 1AT, UK
| | - Ok-Ryul Song
- High Throughput Screening Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Christophe Queval
- High Throughput Screening Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Caitlin Kavanagh
- High Throughput Screening Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Emma C Wall
- Tuberculosis Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; University College London Hospitals NHS Foundation Trust Biomedical Research Centre, London, WC1E 6BT, UK
| | - Edward J Carr
- Cell Biology of Infection Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Sina Namjou
- Safety, Health & Sustainability, The Francis Crick Institute, London, NW1 1AT, UK
| | - Simon Caidan
- Safety, Health & Sustainability, The Francis Crick Institute, London, NW1 1AT, UK
| | - Mike Gavrielides
- Scientific Computing Scientific Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - James I MacRae
- Metabolomics Scientific Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - Gavin Kelly
- Department of Bioinformatics and Biostatistics, The Francis Crick Institute, London, UK
| | - Kema Peat
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Denise Kelly
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Aida Murra
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Kayleigh Kelly
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Molly O'Flaherty
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Robyn L Shea
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, NW1 1AT, UK; Translational Cancer Biochemistry Laboratory, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Gail Gardner
- Translational Cancer Biochemistry Laboratory, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Darren Murray
- Translational Cancer Biochemistry Laboratory, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Nadia Yousaf
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK; Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Shaman Jhanji
- Anaesthetics, Perioperative Medicine, and Pain Department, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Nicholas Van As
- Clincal Oncology Unit, The Royal Marsden NHS Foundation Trust, London, NW1 1AT, UK
| | - Kate Young
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Andrew J S Furness
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lisa Pickering
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Rupert Beale
- University College London Hospitals NHS Foundation Trust Biomedical Research Centre, London, WC1E 6BT, UK; Division of Medicine, University College London, London NW1 2PG, UK
| | - Charles Swanton
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; University College London Cancer Institute, London WC1E 6DD, UK
| | - Sonia Gandhi
- Neurodegeneration Biology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Steve Gamblin
- Structural Biology of Disease Processes Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - David L V Bauer
- RNA Virus Replication Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - George Kassiotis
- Retroviral Immunology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Michael Howell
- High Throughput Screening Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Emma Nicholson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Susanna Walker
- Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Robert J Wilkinson
- Tuberculosis Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; Wellcome Center for Infectious Disease Research in Africa, University of Cape Town, Observatory 7925, Republic of South Africa; Department of Infectious Disease, Imperial College London, London, W12 0NN, UK
| | - James Larkin
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Samra Turajlic
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK.
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14
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Milliken D, Rooms M, Moonesinghe SR, Jhanji S. Peak power output testing: novel method for preoperative assessment of exercise capacity. Br J Surg 2021; 109:220-226. [PMID: 34931236 DOI: 10.1093/bjs/znab408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 10/28/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Assessment of exercise capacity is an important component of risk assessment before major surgery. Cardiopulmonary exercise testing (CPET) provides comprehensive assessment but is resource-intensive, limiting widespread adoption. Measurement of a patient's peak power output (PPO) using a simplified test on a cycle ergometer has the potential to identify patients likely to have abnormal CPET findings and to be at increased perioperative risk. The aim of this study was to investigate the potential for PPO to identify those with abnormal CPET and to determine whether PPO predicted the risk of adverse postoperative outcomes. METHODS In a retrospective analysis of a single-centre cohort, the ability of PPO to predict a high-risk CPET result in patients undergoing major cancer surgery was analysed. The assessment was validated in patients undergoing major abdominal surgery from a UK national multicentre cohort. The association between PPO and adverse postoperative outcomes to traditional CPET-derived variables were compared. RESULTS In 2262 patients from a single centre, PPO was an excellent discriminator of high-risk CPET, with an area under the receiver operating characteristic curve (AUROC) of 0.901 (95 per cent c.i. 0.888 to 0.913). In the national cohort of 2742 patients, there was excellent discrimination, with an AUROC of 0.856 (0.842 to 0.871). A PPO cut-off of 1.5 W/kg may be appropriate for use in screening, with a sensitivity of 90 per cent in both cohorts. PPO and traditional CPET-derived predictors demonstrated similar discrimination of major postoperative complications and death. The association between PPO and major postoperative complications persisted on multivariable analysis. CONCLUSION These results suggest a role for the PPO test in preoperative screening and risk stratification for major surgery. Prospective evaluation is recommended.
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Affiliation(s)
- Don Milliken
- Department of Perioperative Medicine, Anaesthesia, Pain and Critical Care, Royal Marsden NHS Foundation Trust, London, UK
| | - Martin Rooms
- Department of Perioperative Medicine, Anaesthesia, Pain and Critical Care, Royal Marsden NHS Foundation Trust, London, UK
| | - S Ramani Moonesinghe
- Surgical Outcomes Research Centre, Centre for Perioperative Medicine, University College London, London, UK
| | - Shaman Jhanji
- Anaesthesia, Perioperative and Critical Care Medicine, Royal Marsden NHS Foundation Trust, London, UK.,Perioperative and Critical Care Outcomes Group, Division of Cancer Biology, Institute of Cancer Research, London, UK
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15
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Fendler A, Shepherd ST, Au L, Wilkinson KA, Wu M, Byrne F, Cerrone M, Schmitt AM, Joharatnam-Hogan N, Shum B, Tippu Z, Rzeniewicz K, Boos LA, Harvey R, Carlyle E, Edmonds K, Del Rosario L, Sarker S, Lingard K, Mangwende M, Holt L, Ahmod H, Korteweg J, Foley T, Bazin J, Gordon W, Barber T, Emslie-Henry A, Xie W, Gerard CL, Deng D, Wall EC, Agua-Doce A, Namjou S, Caidan S, Gavrielides M, MacRae JI, Kelly G, Peat K, Kelly D, Murra A, Kelly K, O’Flaherty M, Dowdie L, Ash N, Gronthoud F, Shea RL, Gardner G, Murray D, Kinnaird F, Cui W, Pascual J, Rodney S, Mencel J, Curtis O, Stephenson C, Robinson A, Oza B, Farag S, Leslie I, Rogiers A, Iyengar S, Ethell M, Messiou C, Cunningham D, Chau I, Starling N, Turner N, Welsh L, van As N, Jones RL, Droney J, Banerjee S, Tatham KC, O’Brien M, Harrington K, Bhide S, Okines A, Reid A, Young K, Furness AJ, Pickering L, Swanton C, Gandhi S, Gamblin S, Bauer DLV, Kassiotis G, Kumar S, Yousaf N, Jhanji S, Nicholson E, Howell M, Walker S, Wilkinson RJ, Larkin J, Turajlic S. Adaptive immunity and neutralizing antibodies against SARS-CoV-2 variants of concern following vaccination in patients with cancer: The CAPTURE study. Nat Cancer 2021; 2:1321-1337. [PMID: 34950880 PMCID: PMC7612125 DOI: 10.1038/s43018-021-00274-w] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/17/2021] [Indexed: 12/13/2022]
Abstract
CAPTURE (NCT03226886) is a prospective cohort study of COVID-19 immunity in patients with cancer. Here we evaluated 585 patients following administration of two doses of BNT162b2 or AZD1222 vaccines, administered 12 weeks apart. Seroconversion rates after two doses were 85% and 59% in patients with solid and hematological malignancies, respectively. A lower proportion of patients had detectable neutralizing antibody titers (NAbT) against SARS-CoV-2 variants of concern (VOCs) vs wildtype (WT). Patients with hematological malignancies were more likely to have undetectable NAbT and had lower median NAbT vs solid cancers against both WT and VOCs. In comparison with individuals without cancer, patients with haematological, but not solid, malignancies had reduced NAb responses. Seroconversion showed poor concordance with NAbT against VOCs. Prior SARS-CoV-2 infection boosted NAb response including against VOCs, and anti-CD20 treatment was associated with undetectable NAbT. Vaccine-induced T-cell responses were detected in 80% of patients, and were comparable between vaccines or cancer types. Our results have implications for the management of cancer patients during the ongoing COVID-19 pandemic.
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Affiliation(s)
- Annika Fendler
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Scott T.C. Shepherd
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lewis Au
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Katalin A. Wilkinson
- Tuberculosis Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Wellcome Center for Infectious Disease Research in Africa, University of Cape Town, Observatory, Cape Town, Republic of South Africa
| | - Mary Wu
- Wellcome Center for Infectious Disease Research in Africa, University of Cape Town, Observatory, Cape Town, Republic of South Africa
| | - Fiona Byrne
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Maddalena Cerrone
- Tuberculosis Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Department of Infectious Disease, Imperial College London, London, UK
| | - Andreas M. Schmitt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | | | - Benjamin Shum
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Zayd Tippu
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Karolina Rzeniewicz
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Laura Amanda Boos
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Ruth Harvey
- Worldwide Influenza Centre, The Francis Crick Institute, London, NW1 1AT, UK
| | - Eleanor Carlyle
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Kim Edmonds
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lyra Del Rosario
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Sarah Sarker
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Karla Lingard
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Mary Mangwende
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lucy Holt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Hamid Ahmod
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Justine Korteweg
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Tara Foley
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Jessica Bazin
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - William Gordon
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Taja Barber
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Andrea Emslie-Henry
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Wenyi Xie
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Camille L. Gerard
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Daqi Deng
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Emma C. Wall
- University College London Hospitals NHS Foundation Trust Biomedical Research Centre, London, NW1 1AT, UK
- Structural Biology of Disease Processes Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; Experimental Histopathology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Ana Agua-Doce
- Flow Cytometry Scientific Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - Sina Namjou
- Safety, Health & Sustainability, The Francis Crick Institute, London, NW1 1AT, UK
| | - Simon Caidan
- Safety, Health & Sustainability, The Francis Crick Institute, London, NW1 1AT, UK
| | - Mike Gavrielides
- Scientific Computing Scientific Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - James I MacRae
- Metabolomics Scientific Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - Gavin Kelly
- Department of Bioinformatics and Biostatistics, The Francis Crick Institute, London, UK
| | - Kema Peat
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Denise Kelly
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Aida Murra
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Kayleigh Kelly
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Molly O’Flaherty
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lauren Dowdie
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Natalie Ash
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Firza Gronthoud
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, NW1 1AT, UK
| | - Robyn L. Shea
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, NW1 1AT, UK
- Translational Cancer Biochemistry Laboratory, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Gail Gardner
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, NW1 1AT, UK
| | - Darren Murray
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, NW1 1AT, UK
| | - Fiona Kinnaird
- Clinical Trials Unit, The Royal Marsden NHS Foundation Trust, London, SM2 5PT, UK
| | - Wanyuan Cui
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Javier Pascual
- Breast Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Simon Rodney
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Justin Mencel
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey SM2 5PT
| | - Olivia Curtis
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Clemency Stephenson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Anna Robinson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Bhavna Oza
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Sheima Farag
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Isla Leslie
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Aljosja Rogiers
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Sunil Iyengar
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Mark Ethell
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Christina Messiou
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - David Cunningham
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey SM2 5PT
| | - Ian Chau
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey SM2 5PT
| | - Naureen Starling
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey SM2 5PT
| | - Nicholas Turner
- Breast Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Liam Welsh
- Neuro-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Nicholas van As
- Clinical Oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Robin L. Jones
- Sarcoma Unit, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, SW3 6JJ, UK
| | - Joanne Droney
- Palliative Medicine, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Susana Banerjee
- Gynaecology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Kate C. Tatham
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Mary O’Brien
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Kevin Harrington
- Head and Neck, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
- Targeted Therapy Team, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Shreerang Bhide
- Head and Neck, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
- Targeted Therapy Team, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Alicia Okines
- Breast Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
- Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Alison Reid
- Uro-oncology unit, The Royal Marsden NHS Foundation Trust, Surrey, SM2 5PT
| | - Kate Young
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Andrew J.S. Furness
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lisa Pickering
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Charles Swanton
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- University College London Cancer Institute, London WC1E 6DD, UK
| | | | - Sonia Gandhi
- Neurodegeneration Biology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG
| | - Steve Gamblin
- Structural Biology of Disease Processes Laboratory, The Francis Crick Institute, London, NW1 1AT, UK; Experimental Histopathology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - David LV Bauer
- RNA Virus Replication Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - George Kassiotis
- Retroviral Immunology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Sacheen Kumar
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey SM2 5PT
| | - Nadia Yousaf
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
- Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Shaman Jhanji
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Emma Nicholson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Michael Howell
- High Throughput Screening Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Susanna Walker
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Robert J. Wilkinson
- Tuberculosis Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Wellcome Center for Infectious Disease Research in Africa, University of Cape Town, Observatory, Cape Town, Republic of South Africa
- Department of Infectious Disease, Imperial College London, London, UK
| | - James Larkin
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Samra Turajlic
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
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16
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Fendler A, Au L, Shepherd STC, Byrne F, Cerrone M, Boos LA, Rzeniewicz K, Gordon W, Shum B, Gerard CL, Ward B, Xie W, Schmitt AM, Joharatnam-Hogan N, Cornish GH, Pule M, Mekkaoui L, Ng KW, Carlyle E, Edmonds K, Rosario LD, Sarker S, Lingard K, Mangwende M, Holt L, Ahmod H, Stone R, Gomes C, Flynn HR, Agua-Doce A, Hobson P, Caidan S, Howell M, Wu M, Goldstone R, Crawford M, Cubitt L, Patel H, Gavrielides M, Nye E, Snijders AP, MacRae JI, Nicod J, Gronthoud F, Shea RL, Messiou C, Cunningham D, Chau I, Starling N, Turner N, Welsh L, van As N, Jones RL, Droney J, Banerjee S, Tatham KC, Jhanji S, O'Brien M, Curtis O, Harrington K, Bhide S, Bazin J, Robinson A, Stephenson C, Slattery T, Khan Y, Tippu Z, Leslie I, Gennatas S, Okines A, Reid A, Young K, Furness AJS, Pickering L, Gandhi S, Gamblin S, Swanton C, Nicholson E, Kumar S, Yousaf N, Wilkinson KA, Swerdlow A, Harvey R, Kassiotis G, Larkin J, Wilkinson RJ, Turajlic S. Functional antibody and T cell immunity following SARS-CoV-2 infection, including by variants of concern, in patients with cancer: the CAPTURE study. Nat Cancer 2021; 2:1321-1337. [PMID: 35121900 DOI: 10.1038/s43018-021-00275-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/17/2021] [Indexed: 12/13/2022]
Abstract
Patients with cancer have higher COVID-19 morbidity and mortality. Here we present the prospective CAPTURE study, integrating longitudinal immune profiling with clinical annotation. Of 357 patients with cancer, 118 were SARS-CoV-2 positive, 94 were symptomatic and 2 died of COVID-19. In this cohort, 83% patients had S1-reactive antibodies and 82% had neutralizing antibodies against wild type SARS-CoV-2, whereas neutralizing antibody titers against the Alpha, Beta and Delta variants were substantially reduced. S1-reactive antibody levels decreased in 13% of patients, whereas neutralizing antibody titers remained stable for up to 329 days. Patients also had detectable SARS-CoV-2-specific T cells and CD4+ responses correlating with S1-reactive antibody levels, although patients with hematological malignancies had impaired immune responses that were disease and treatment specific, but presented compensatory cellular responses, further supported by clinical recovery in all but one patient. Overall, these findings advance the understanding of the nature and duration of the immune response to SARS-CoV-2 in patients with cancer.
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Affiliation(s)
- Annika Fendler
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| | - Lewis Au
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Scott T C Shepherd
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Fiona Byrne
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| | - Maddalena Cerrone
- Tuberculosis Laboratory, The Francis Crick Institute, London, UK
- Department of Infectious Disease, Imperial College London, London, UK
| | - Laura Amanda Boos
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | | | - William Gordon
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| | - Benjamin Shum
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Camille L Gerard
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| | - Barry Ward
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| | - Wenyi Xie
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| | - Andreas M Schmitt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Georgina H Cornish
- Retroviral Immunology Laboratory, The Francis Crick Institute, London, UK
| | - Martin Pule
- Department of Haematology, University College London Cancer Institute, London, UK
- Autolus Ltd., London, UK
| | | | - Kevin W Ng
- Retroviral Immunology Laboratory, The Francis Crick Institute, London, UK
| | - Eleanor Carlyle
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Kim Edmonds
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Lyra Del Rosario
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Sarah Sarker
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Karla Lingard
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Mary Mangwende
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Lucy Holt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Hamid Ahmod
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Richard Stone
- Experimental Histopathology Laboratory, The Francis Crick Institute, London, UK
| | - Camila Gomes
- Experimental Histopathology Laboratory, The Francis Crick Institute, London, UK
| | - Helen R Flynn
- Mass Spectrometry Proteomics Science Technology Platform, The Francis Crick Institute, London, UK
| | - Ana Agua-Doce
- Flow Cytometry Scientific Technology Platform, The Francis Crick Institute, London, UK
| | - Philip Hobson
- Flow Cytometry Scientific Technology Platform, The Francis Crick Institute, London, UK
| | - Simon Caidan
- Safety, Health and Sustainability, The Francis Crick Institute, London, UK
| | - Michael Howell
- High Throughput Screening Laboratory, The Francis Crick Institute, London, UK
| | - Mary Wu
- High Throughput Screening Laboratory, The Francis Crick Institute, London, UK
| | - Robert Goldstone
- Advanced Sequencing Facility, The Francis Crick Institute, London, UK
| | - Margaret Crawford
- Advanced Sequencing Facility, The Francis Crick Institute, London, UK
| | - Laura Cubitt
- Advanced Sequencing Facility, The Francis Crick Institute, London, UK
| | - Harshil Patel
- Department of Bioinformatics and Biostatistics, The Francis Crick Institute, London, UK
| | - Mike Gavrielides
- Scientific Computing Scientific Technology Platform, The Francis Crick Institute, London, UK
| | - Emma Nye
- Experimental Histopathology Laboratory, The Francis Crick Institute, London, UK
| | - Ambrosius P Snijders
- Mass Spectrometry Proteomics Science Technology Platform, The Francis Crick Institute, London, UK
| | - James I MacRae
- Metabolomics Scientific Technology Platform, The Francis Crick Institute, London, UK
| | - Jerome Nicod
- Advanced Sequencing Facility, The Francis Crick Institute, London, UK
| | - Firza Gronthoud
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Robyn L Shea
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, UK
- Translational Cancer Biochemistry Laboratory, The Institute of Cancer Research, London, UK
| | - Christina Messiou
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
| | - David Cunningham
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, London, UK
| | - Ian Chau
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, London, UK
| | - Naureen Starling
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, London, UK
| | - Nicholas Turner
- Breast Unit, The Royal Marsden NHS Foundation Trust, London, UK
- Breast Cancer Now Toby Robins Breast Cancer Research Centre, The Institute of Cancer Research, London, UK
| | - Liam Welsh
- Neuro-oncology Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Nicholas van As
- Clinical Oncology Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Robin L Jones
- Sarcoma Unit, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - Joanne Droney
- Palliative Medicine, The Royal Marsden NHS Foundation Trust, London, UK
| | - Susana Banerjee
- Gynaecology Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Kate C Tatham
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Shaman Jhanji
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - Mary O'Brien
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Olivia Curtis
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Kevin Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
- Targeted Therapy Team, The Institute of Cancer Research, London, UK
| | - Shreerang Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
- Targeted Therapy Team, The Institute of Cancer Research, London, UK
| | - Jessica Bazin
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Anna Robinson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Tim Slattery
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Yasir Khan
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Zayd Tippu
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Isla Leslie
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Spyridon Gennatas
- Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, UK
- Department of Medical Oncology, Guy's Hospital, London, UK
| | - Alicia Okines
- Breast Unit, The Royal Marsden NHS Foundation Trust, London, UK
- Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, UK
| | - Alison Reid
- Uro-oncology Unit, The Royal Marsden NHS Foundation Trust, Surrey, UK
| | - Kate Young
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Andrew J S Furness
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Lisa Pickering
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Sonia Gandhi
- Neurodegeneration Biology Laboratory, The Francis Crick Institute, London, UK
- UCL Queen Square Institute of Neurology, London, UK
| | - Steve Gamblin
- Structural Biology of Disease Processes Laboratory, The Francis Crick Institute, London, UK
| | - Charles Swanton
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London, UK
- University College London Cancer Institute, London, UK
| | - Emma Nicholson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Sacheen Kumar
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, London, UK
| | - Nadia Yousaf
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, UK
- Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, UK
| | - Katalin A Wilkinson
- Tuberculosis Laboratory, The Francis Crick Institute, London, UK
- Wellcome Center for Infectious Disease Research in Africa, University Cape Town, Cape Town, Republic of South Africa
| | - Anthony Swerdlow
- Division of Genetics and Epidemiology and Division of Breast Cancer Research, The Institute of Cancer Research, London, UK
| | - Ruth Harvey
- Worldwide Influenza Centre, The Francis Crick Institute, London, UK
| | - George Kassiotis
- Retroviral Immunology Laboratory, The Francis Crick Institute, London, UK
| | - James Larkin
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Robert J Wilkinson
- Tuberculosis Laboratory, The Francis Crick Institute, London, UK
- Department of Infectious Disease, Imperial College London, London, UK
- Wellcome Center for Infectious Disease Research in Africa, University Cape Town, Cape Town, Republic of South Africa
| | - Samra Turajlic
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK.
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK.
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17
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Tiu C, Shinde R, Pal A, Biondo A, Lee A, Tunariu N, Jhanji S, Grover V, Tatham K, Gruber P, Banerji U, De Bono JS, Nicholson E, Minchom AR, Lopez JS. A Wolf in Sheep's Clothing: Systemic Immune Activation Post Immunotherapy. Journal of Immunotherapy and Precision Oncology 2021; 4:189-195. [PMID: 35665022 PMCID: PMC9138480 DOI: 10.36401/jipo-21-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/25/2022]
Abstract
Introduction Immune checkpoint inhibitors (ICIs) are increasingly a standard of care for many cancers; these agents can result in immune-related adverse events (irAEs) including fever, which is common but can rarely be associated with systemic immune activation (SIA or acquired HLH). Methods All consecutive patients receiving ICIs in the Drug Development Unit of the Royal Marsden Hospital between May 2014 and November 2019 were retrospectively reviewed. Patients with fever ≥ 38°C or chills/rigors (without fever) ≤ 6 weeks of commencing ICIs were identified for clinical data collection. Results Three patients met diagnostic criteria for SIA/HLH with median time to onset of symptoms of 10 days. We describe the clinical evolution, treatment used, and outcomes for these patients. High-dose steroids are used first-line with other treatments, such as tocilizumab, immunoglobulin and therapeutic plasmapheresis can be considered for steroid-refractory SIA/HLH. Conclusion SIA/HLH post ICI is a rare but a potentially fatal irAE that presents with fever and a constellation of nonspecific symptoms. Early recognition and timely treatment are key to improving outcomes.
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Affiliation(s)
- Crescens Tiu
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Rajiv Shinde
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Abhijit Pal
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Andrea Biondo
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Alex Lee
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Nina Tunariu
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Shaman Jhanji
- Critical Care Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Vimal Grover
- Critical Care Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Kate Tatham
- Critical Care Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Pascale Gruber
- Critical Care Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Udai Banerji
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Johann S. De Bono
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Emma Nicholson
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Anna R. Minchom
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Juanita S. Lopez
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
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18
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Nadkarni Y, Kukec I, Gruber P, Jhanji S, Droney J. Integrated palliative care: triggers for referral to palliative care in ICU patients. Support Care Cancer 2021; 30:2173-2181. [PMID: 34704155 DOI: 10.1007/s00520-021-06542-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 09/03/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Palliative care within intensive care units (ICU) benefits decision-making, symptom control, and end-of-life care. It has been shown to reduce the length of ICU stay and the use of non-beneficial and unwanted life-sustaining therapies. However, it is often initiated late or not at all. There is increasing evidence to support screening ICU patients using palliative care referral criteria or "triggers". The aim of the project was to assess the need for palliative care referral during ICU admission using "trigger" tools. METHODS Electronic record review of cancer patients who died in or within 30 days of discharge from oncology ICU, between 2016 and 2018. Patients referred to palliative care before or during ICU admission were identified. Three sets of palliative care referral "triggers" were applied: one that is being tested locally and two internationally derived tools. The proportion of patients who met any of these triggers during their final ICU admission was calculated. RESULTS Records of 149 patients were reviewed: median age 65 (range 20-83). Most admissions (89%) were unplanned, with the most common diagnoses being haemato-oncology (31%) and gastrointestinal (16%) cancers. Most (73%) were unknown to palliative care pre-ICU admission; 44% were referred between admission and death. The median time from referral to death was 0 day (range 0-19). On ICU admission, 97-99% warranted referral to palliative care using locally and internationally derived triggers. CONCLUSION All "trigger" tools identified a high proportion of patients who may have warranted a palliative care referral either before or during admission to ICU. The routine use of trigger tools could help streamline referral pathways and underpin the development of an effective consultative model of palliative care within the ICU setting to enhance decision-making about appropriate treatment and patient-centred care.
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Affiliation(s)
- Yashna Nadkarni
- Critical Care Unit, Anaesthetics Department, Royal Marsden NHS Foundation Trust, London, UK.
| | - Ivana Kukec
- University Hospital Centre Zagreb, Zagreb, Croatia
| | - Pascale Gruber
- Critical Care Unit, Anaesthetics Department, Royal Marsden NHS Foundation Trust, London, UK
| | - Shaman Jhanji
- Critical Care Unit, Anaesthetics Department, Royal Marsden NHS Foundation Trust, London, UK
| | - Joanne Droney
- Symptom Control and Palliative Care Team, Royal Marsden NHS Foundation Trust, London, UK
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19
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Fendler A, Au L, Shepherd ST, Byrne F, Cerrone M, Boos LA, Rzeniewicz K, Gordon W, Shum B, Gerard CL, Ward B, Xie W, Schmitt AM, Joharatnam-Hogan N, Cornish GH, Pule M, Mekkaoui L, Ng KW, Carlyle E, Edmonds K, Del Rosario L, Sarker S, Lingard K, Mangwende M, Holt L, Ahmod H, Stone R, Gomes C, Flynn HR, Agua-Doce A, Hobson P, Caidan S, Howell M, Wu M, Goldstone R, Crawford M, Cubitt L, Patel H, Gavrielides M, Nye E, Snijders AP, MacRae JI, Nicod J, Gronthoud F, Shea RL, Messiou C, Cunningham D, Chau I, Starling N, Turner N, Welsh L, van As N, Jones RL, Droney J, Banerjee S, Tatham KC, Jhanji S, O’Brien M, Curtis O, Harrington K, Bhide S, Bazin J, Robinson A, Stephenson C, Slattery T, Khan Y, Tippu Z, Leslie I, Gennatas S, Okines A, Reid A, Young K, Furness AJ, Pickering L, Gandhi S, Gamblin S, Swanton C, Nicholson E, Kumar S, Yousaf N, Wilkinson KA, Swerdlow A, Harvey R, Kassiotis G, Larkin J, Wilkinson RJ, Turajlic S. Functional antibody and T-cell immunity following SARS-CoV-2 infection, including by variants of concern, in patients with cancer: the CAPTURE study. Res Sq 2021:rs.3.rs-916427. [PMID: 34580668 PMCID: PMC8475970 DOI: 10.21203/rs.3.rs-916427/v1] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Patients with cancer have higher COVID-19 morbidity and mortality. Here we present the prospective CAPTURE study (NCT03226886) integrating longitudinal immune profiling with clinical annotation. Of 357 patients with cancer, 118 were SARS-CoV-2-positive, 94 were symptomatic and 2 patients died of COVID-19. In this cohort, 83% patients had S1-reactive antibodies, 82% had neutralizing antibodies against WT, whereas neutralizing antibody titers (NAbT) against the Alpha, Beta, and Delta variants were substantially reduced. Whereas S1-reactive antibody levels decreased in 13% of patients, NAbT remained stable up to 329 days. Patients also had detectable SARS-CoV-2-specific T cells and CD4+ responses correlating with S1-reactive antibody levels, although patients with hematological malignancies had impaired immune responses that were disease and treatment-specific, but presented compensatory cellular responses, further supported by clinical. Overall, these findings advance the understanding of the nature and duration of immune response to SARS-CoV-2 in patients with cancer.
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Affiliation(s)
- Annika Fendler
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Equal contribution
| | - Lewis Au
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
- Equal contribution
| | - Scott T.C. Shepherd
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
- Equal contribution
| | - Fiona Byrne
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Maddalena Cerrone
- Tuberculosis Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Department of Infectious Disease, Imperial College London, W12 0NN, UK
| | - Laura Amanda Boos
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Karolina Rzeniewicz
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - William Gordon
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Ben Shum
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Camille L. Gerard
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Barry Ward
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Wenyi Xie
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Andreas M. Schmitt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | | | - Georgina H. Cornish
- Retroviral Immunology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Martin Pule
- Research Department of Haematology at University College London Cancer Institute, WC1E 6DD, London, UK
- Autolus Limited, The MediaWorks, 191 Wood Lane, London, W12 7F
| | - Leila Mekkaoui
- Autolus Limited, The MediaWorks, 191 Wood Lane, London, W12 7F
| | - Kevin W. Ng
- Retroviral Immunology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Eleanor Carlyle
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Kim Edmonds
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lyra Del Rosario
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Sarah Sarker
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Karla Lingard
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Mary Mangwende
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lucy Holt
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Hamid Ahmod
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Richard Stone
- Autolus Limited, The MediaWorks, 191 Wood Lane, London, W12 7F
| | - Camila Gomes
- Autolus Limited, The MediaWorks, 191 Wood Lane, London, W12 7F
| | - Helen R. Flynn
- Mass Spectrometry Proteomics Science Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - Ana Agua-Doce
- Flow Cytometry Scientific Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - Philip Hobson
- Flow Cytometry Scientific Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - Simon Caidan
- Safety, Health & Sustainability, The Francis Crick Institute, London, NW1 1AT, UK
| | - Michael Howell
- High Throughput Screening Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Mary Wu
- High Throughput Screening Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Robert Goldstone
- Advanced Sequencing Facility, The Francis Crick Institute, London, NW1 1AT, UK
| | - Margaret Crawford
- Advanced Sequencing Facility, The Francis Crick Institute, London, NW1 1AT, UK
| | - Laura Cubitt
- Advanced Sequencing Facility, The Francis Crick Institute, London, NW1 1AT, UK
| | - Harshil Patel
- Department of Bioinformatics and Biostatistics, The Francis Crick Institute, London, UK
| | - Mike Gavrielides
- Scientific Computing Scientific Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - Emma Nye
- Experimental Histopathology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Ambrosius P Snijders
- Mass Spectrometry Proteomics Science Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - James I MacRae
- Metabolomics Scientific Technology Platform, The Francis Crick Institute, London, NW1 1AT, UK
| | - Jerome Nicod
- Advanced Sequencing Facility, The Francis Crick Institute, London, NW1 1AT, UK
| | - Firza Gronthoud
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, NW1 1AT, UK
| | - Robyn L. Shea
- Department of Pathology, The Royal Marsden NHS Foundation Trust, London, NW1 1AT, UK
- Translational Cancer Biochemistry Laboratory, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Christina Messiou
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - David Cunningham
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey SM2 5PT
| | - Ian Chau
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey SM2 5PT
| | - Naureen Starling
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey SM2 5PT
| | - Nicholas Turner
- Breast Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Liam Welsh
- Neuro-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Nicholas van As
- Clinical Oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Robin L. Jones
- Sarcoma Unit, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, SW3 6JJ, UK
| | - Joanne Droney
- Palliative Medicine, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Susana Banerjee
- Gynaecology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Kate C. Tatham
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Shaman Jhanji
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Mary O’Brien
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Olivia Curtis
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Kevin Harrington
- Head and Neck, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
- Targeted Therapy Team, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Shreerang Bhide
- Head and Neck, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Jessica Bazin
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Anna Robinson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Clemency Stephenson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Tim Slattery
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Yasir Khan
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Zayd Tippu
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Isla Leslie
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Spyridon Gennatas
- Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
- Department of Medical Oncology, 14th Floor, Great Maze Pond Road, Tower Wing, Guy’s Hospital, London SE1 9RY, UK
| | - Alicia Okines
- Breast Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
- Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Alison Reid
- Uro-oncology unit, The Royal Marsden NHS Foundation Trust, Surrey, SM2 5PT
| | - Kate Young
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Andrew J.S. Furness
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Lisa Pickering
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Sonia Gandhi
- Neurodegeneration Biology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG
| | - Steve Gamblin
- Structural Biology of Disease Processes Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - Charles Swanton
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- University College London Cancer Institute, London WC1E 6DD, UK
| | - Emma Nicholson
- Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Sacheen Kumar
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London and Surrey SM2 5PT
| | - Nadia Yousaf
- Lung Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
- Acute Oncology Service, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Katalin A. Wilkinson
- Tuberculosis Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Wellcome Center for Infectious Disease Research in Africa, University Cape Town, Observatory 7925, Republic of South Africa
| | - Anthony Swerdlow
- Division of Genetics and Epidemiology and Division of Breast Cancer Research, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Ruth Harvey
- Worldwide Influenza Centre, The Francis Crick Institute, London, NW1 1AT, UK
| | - George Kassiotis
- Retroviral Immunology Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
| | - James Larkin
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Robert J. Wilkinson
- Tuberculosis Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Department of Infectious Disease, Imperial College London, W12 0NN, UK
- Wellcome Center for Infectious Disease Research in Africa, University Cape Town, Observatory 7925, Republic of South Africa
| | - Samra Turajlic
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, NW1 1AT, UK
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
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20
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Loveday C, Sud A, Jones ME, Broggio J, Scott S, Gronthound F, Torr B, Garrett A, Nicol DL, Jhanji S, Boyce SA, Williams M, Barry C, Riboli E, Kipps E, McFerran E, Muller DC, Lyratzopoulos G, Lawler M, Abulafi M, Houlston RS, Turnbull C. Prioritisation by FIT to mitigate the impact of delays in the 2-week wait colorectal cancer referral pathway during the COVID-19 pandemic: a UK modelling study. Gut 2021; 70:1053-1060. [PMID: 32855306 PMCID: PMC7447105 DOI: 10.1136/gutjnl-2020-321650] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/06/2020] [Accepted: 08/09/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the impact of faecal immunochemical testing (FIT) prioritisation to mitigate the impact of delays in the colorectal cancer (CRC) urgent diagnostic (2-week-wait (2WW)) pathway consequent from the COVID-19 pandemic. DESIGN We modelled the reduction in CRC survival and life years lost resultant from per-patient delays of 2-6 months in the 2WW pathway. We stratified by age group, individual-level benefit in CRC survival versus age-specific nosocomial COVID-19-related fatality per referred patient undergoing colonoscopy. We modelled mitigation strategies using thresholds of FIT triage of 2, 10 and 150 µg Hb/g to prioritise 2WW referrals for colonoscopy. To construct the underlying models, we employed 10-year net CRC survival for England 2008-2017, 2WW pathway CRC case and referral volumes and per-day-delay HRs generated from observational studies of diagnosis-to-treatment interval. RESULTS Delay of 2/4/6 months across all 11 266 patients with CRC diagnosed per typical year via the 2WW pathway were estimated to result in 653/1419/2250 attributable deaths and loss of 9214/20 315/32 799 life years. Risk-benefit from urgent investigatory referral is particularly sensitive to nosocomial COVID-19 rates for patients aged >60. Prioritisation out of delay for the 18% of symptomatic referrals with FIT >10 µg Hb/g would avoid 89% of these deaths attributable to presentational/diagnostic delay while reducing immediate requirement for colonoscopy by >80%. CONCLUSIONS Delays in the pathway to CRC diagnosis and treatment have potential to cause significant mortality and loss of life years. FIT triage of symptomatic patients in primary care could streamline access to colonoscopy, reduce delays for true-positive CRC cases and reduce nosocomial COVID-19 mortality in older true-negative 2WW referrals. However, this strategy offers benefit only in short-term rationalisation of limited endoscopy services: the appreciable false-negative rate of FIT in symptomatic patients means most colonoscopies will still be required.
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Affiliation(s)
- Chey Loveday
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Amit Sud
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Michael E Jones
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - John Broggio
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | - Stephen Scott
- RM Partners, West London Cancer Alliance, London, UK
| | | | - Beth Torr
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Alice Garrett
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - David L Nicol
- Urology Unit, Royal Marsden NHS Foundation Trust, London, UK
- Division of Clinical Studies, Institute of Cancer Research, London, UK
| | - Shaman Jhanji
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden NHS Foundation Trust, London, UK
- Division of Cancer Biology, Institute of Cancer Research, London, UK
| | - Stephen A Boyce
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matthew Williams
- Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK
- Computational Oncology Group, Imperial College London, London, UK
| | - Claire Barry
- RM Partners, West London Cancer Alliance, London, UK
| | - Elio Riboli
- School of Public Health, Imperial College London, London, UK
| | - Emma Kipps
- RM Partners, West London Cancer Alliance, London, UK
- The Breast Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Ethna McFerran
- Patrick G Johnston Centre for Cancer Research, Queens University Belfast, Belfast, UK
| | - David C Muller
- The Breast Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Georgios Lyratzopoulos
- National Cancer Registration and Analysis Service, Public Health England, London, UK
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, University College London, London, UK
| | - Mark Lawler
- Patrick G Johnston Centre for Cancer Research, Queens University Belfast, Belfast, UK
| | - Muti Abulafi
- Colorectal Surgery, Croydon Health Services NHS Trust, Croydon, London, UK
| | - Richard S Houlston
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
- Department of Clinical Genetics, Royal Marsden NHS Foundation Trust, London, UK
| | - Clare Turnbull
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
- National Cancer Registration and Analysis Service, Public Health England, London, UK
- Department of Clinical Genetics, Royal Marsden NHS Foundation Trust, London, UK
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21
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Kasivisvanathan R, Tilney HS, Jhanji S, O’Mahony M, Gruber P, Nicol D, Morgan D, Kipps E, Rasheed S. The 'hub and spoke model' for the management of surgical patients during the COVID-19 pandemic. Int J Health Plann Manage 2021; 36:1397-1406. [PMID: 34046937 PMCID: PMC8239827 DOI: 10.1002/hpm.3243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/02/2021] [Accepted: 05/10/2021] [Indexed: 01/10/2023] Open
Abstract
During the on-going COVID-19 pandemic a number of key public health services have been severely impacted. These include elective surgical services due to the synergetic resources required to provide both perioperative surgical care whilst also treating acute COVID-19 patients and also the poor outcomes associated with surgical patients who develop COVID-19 in the perioperative period. This article discusses the important principles and concepts for providing important surgical services during the COVID-19 pandemic based on the model of the RMCancerSurgHub which is providing surgical cancer services for a population of approximately 2 million people across London during the pandemic. The model focusses on creating local and regional hub centres which provide urgent treatment for surgical patients in an environment that is relatively protected from the burden of COVID-19 illness. The model extensively utilises the extended multidisciplinary team to allow for a flexible approach with core services delivered in 'clean' sites which can adapt to viral surges. A key requirement is that of a clinical prioritisation process which allows for equity in access within and between specialties ensuring that patients are treated on the basis of greatest need, while at the same time protecting those whose conditions can safely wait from exposure to the virus. Importantly, this model has the ability to scale-up activity and lead units and networks into the recovery phase. The model discussed is also broadly applicable to providing surgical services during any viral pandemic.
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Affiliation(s)
| | | | - Shaman Jhanji
- The Royal Marsden NHS Foundation Trust HospitalLondonUK
| | | | | | - David Nicol
- The Royal Marsden NHS Foundation Trust HospitalLondonUK
| | | | - Emma Kipps
- Royal Marsden Partners West London Cancer AllianceLondonUK
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22
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Ap Dafydd D, O'Mahony M, Jhanji S, Devaraj A, Allum W, Nicol D, Blunt DM, Riddell AM. The role of CT chest in screening for asymptomatic COVID-19 infection in self-isolating patients prior to elective oncological surgery: findings from a UK Cancer Hub. Br J Radiol 2020; 94:20200994. [PMID: 33242245 PMCID: PMC7774707 DOI: 10.1259/bjr.20200994] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives: In accordance with initial guidance from the Royal College of Surgeons and Royal College of Radiologists, we evaluated the utility of CT of the chest in the exclusion of asymptomatic COVID-19 infection prior to elective cancer surgery on self-isolating patients during the pandemic. Methods: All surgical referrals without symptoms of COVID-19 infection in April and May 2020 were included. Patient records were retrospectively reviewed. Screening included CT chest for major thoracic and abdominal surgery. CTs were reported according to British Society of Thoracic Imaging guidelines and correlated with reverse transcriptase polymerase chain reaction (RT-PCR) and surgical outcomes. Results: The prevalence of RT-PCR confirmed COVID-19 infection in our screened population was 0.7% (5/681). 240 pre-operative CTs were performed. 3.8% (9/240) of CTs were reported as abnormal, only one of which was RT-PCR positive. 2% (5/240) of cases had surgery postponed based on CT results. All nine patients with CTs reported as abnormal have had surgery, all without complication. Conclusion: The prevalence of asymptomatic COVID-19 infection in our screened population was low. The pre-test probability of CT chest in asymptomatic, self-isolating patients is consequently low. CT can produce false positives in this setting, introducing unnecessary delay in surgery for a small proportion of cases. Advances in knowledge: Self-isolation, clinical assessment and RT-PCR are effective at minimising COVID-19 related surgical risk. The addition of CT chest is unhelpful. Our data have particular relevance during the second wave of infection and in the recovery phase.
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Affiliation(s)
- Derfel Ap Dafydd
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Michelle O'Mahony
- Department of Anaesthetics, The Royal Marsden NHS Foundation Trust, London, UK
| | - Shaman Jhanji
- Department of Anaesthetics, The Royal Marsden NHS Foundation Trust, London, UK
| | - Anand Devaraj
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - William Allum
- Department of Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - David Nicol
- Department of Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Dominic M Blunt
- Department of Radiology, Imperial College Healthcare NHS, Hammersmith, London, UK
| | - Angela M Riddell
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
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Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild L, Thrush J, Wood H, Austin K, Donnelly A, Kelly M, O’Kane S, McClintock D, Warnock M, Johnston P, Gallagher LJ, Mc Goldrick C, Mc Master M, Strzelecka A, Jha R, Kalogirou M, Ellis C, Krishnamurthy V, Deelchand V, Silversides J, McGuigan P, Ward K, O’Neill A, Finn S, Phillips B, Mullan D, Oritz-Ruiz de Gordoa L, Thomas M, Sweet K, Grimmer L, Johnson R, Pinnell J, Robinson M, Gledhill L, Wood T, Morgan M, Cole J, Hill H, Davies M, Antcliffe D, Templeton M, Rojo R, Coghlan P, Smee J, Mackay E, Cort J, Whileman A, Spencer T, Spittle N, Kasipandian V, Patel A, Allibone S, Genetu RM, Ramali M, Ghosh A, Bamford P, London E, Cawley K, Faulkner M, Jeffrey H, Smith T, Brewer C, Gregory J, Limb J, Cowton A, O’Brien J, Nikitas N, Wells C, Lankester L, Pulletz M, Williams P, Birch J, Wiseman S, Horton S, Alegria A, Turki S, Elsefi T, Crisp N, Allen L, McCullagh I, Robinson P, Hays C, Babio-Galan M, Stevenson H, Khare D, Pinder M, Selvamoni S, Gopinath A, Pugh R, Menzies D, Mackay C, Allan E, Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins N, Lewis S, Dell A, Gopal S, Ganguly S, Smallwood A, Harris N, Metherell S, Lazaro JM, Newman T, Fletcher S, Nortje J, Fottrell-Gould D, Randell G, Zaman M, Elmahi E, Jones A, Hall K, Mills G, Ryalls K, Bowler H, Sall J, Bourne R, Borrill Z, Duncan T, Lamb T, Shaw J, Fox C, Moreno Cuesta J, Xavier K, Purohit D, Elhassan M, Bakthavatsalam D, Rowland M, Hutton P, Bashyal A, Davidson N, Hird C, Chhablani M, Phalod G, Kirkby A, Archer S, Netherton K, Reschreiter H, Camsooksai J, Patch S, Jenkins S, Pogson D, Rose S, Daly Z, Brimfield L, Claridge H, Parekh D, Bergin C, Bates M, Dasgin J, McGhee C, Sim M, Hay SK, Henderson S, Phull MK, Zaidi A, Pogreban T, Rosaroso LP, Harvey D, Lowe B, Meredith M, Ryan L, Hormis A, Walker R, Collier D, Kimpton S, Oakley S, Rooney K, Rodden N, Hughes E, Thomson N, McGlynn D, Walden A, Jacques N, Coles H, Tilney E, Vowell E, Schuster-Bruce M, Pitts S, Miln R, Purandare L, Vamplew L, Spivey M, Bean S, Burt K, Moore L, Day C, Gibson C, Gordon E, Zitter L, Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020. [PMID: 32876697 DOI: 10.1001/jama.2020.1702221] [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] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild L, Thrush J, Wood H, Austin K, Donnelly A, Kelly M, O’Kane S, McClintock D, Warnock M, Johnston P, Gallagher LJ, Mc Goldrick C, Mc Master M, Strzelecka A, Jha R, Kalogirou M, Ellis C, Krishnamurthy V, Deelchand V, Silversides J, McGuigan P, Ward K, O’Neill A, Finn S, Phillips B, Mullan D, Oritz-Ruiz de Gordoa L, Thomas M, Sweet K, Grimmer L, Johnson R, Pinnell J, Robinson M, Gledhill L, Wood T, Morgan M, Cole J, Hill H, Davies M, Antcliffe D, Templeton M, Rojo R, Coghlan P, Smee J, Mackay E, Cort J, Whileman A, Spencer T, Spittle N, Kasipandian V, Patel A, Allibone S, Genetu RM, Ramali M, Ghosh A, Bamford P, London E, Cawley K, Faulkner M, Jeffrey H, Smith T, Brewer C, Gregory J, Limb J, Cowton A, O’Brien J, Nikitas N, Wells C, Lankester L, Pulletz M, Williams P, Birch J, Wiseman S, Horton S, Alegria A, Turki S, Elsefi T, Crisp N, Allen L, McCullagh I, Robinson P, Hays C, Babio-Galan M, Stevenson H, Khare D, Pinder M, Selvamoni S, Gopinath A, Pugh R, Menzies D, Mackay C, Allan E, Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins N, Lewis S, Dell A, Gopal S, Ganguly S, Smallwood A, Harris N, Metherell S, Lazaro JM, Newman T, Fletcher S, Nortje J, Fottrell-Gould D, Randell G, Zaman M, Elmahi E, Jones A, Hall K, Mills G, Ryalls K, Bowler H, Sall J, Bourne R, Borrill Z, Duncan T, Lamb T, Shaw J, Fox C, Moreno Cuesta J, Xavier K, Purohit D, Elhassan M, Bakthavatsalam D, Rowland M, Hutton P, Bashyal A, Davidson N, Hird C, Chhablani M, Phalod G, Kirkby A, Archer S, Netherton K, Reschreiter H, Camsooksai J, Patch S, Jenkins S, Pogson D, Rose S, Daly Z, Brimfield L, Claridge H, Parekh D, Bergin C, Bates M, Dasgin J, McGhee C, Sim M, Hay SK, Henderson S, Phull MK, Zaidi A, Pogreban T, Rosaroso LP, Harvey D, Lowe B, Meredith M, Ryan L, Hormis A, Walker R, Collier D, Kimpton S, Oakley S, Rooney K, Rodden N, Hughes E, Thomson N, McGlynn D, Walden A, Jacques N, Coles H, Tilney E, Vowell E, Schuster-Bruce M, Pitts S, Miln R, Purandare L, Vamplew L, Spivey M, Bean S, Burt K, Moore L, Day C, Gibson C, Gordon E, Zitter L, Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020; 324:1317-1329. [PMID: 32876697 PMCID: PMC7489418 DOI: 10.1001/jama.2020.17022] [Citation(s) in RCA: 542] [Impact Index Per Article: 135.5] [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: 01/27/2023]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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25
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Sud A, Jones ME, Broggio J, Loveday C, Torr B, Garrett A, Nicol DL, Jhanji S, Boyce SA, Gronthoud F, Ward P, Handy JM, Yousaf N, Larkin J, Suh YE, Scott S, Pharoah PDP, Swanton C, Abbosh C, Williams M, Lyratzopoulos G, Houlston R, Turnbull C. Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic. Ann Oncol 2020; 31:1065-1074. [PMID: 32442581 PMCID: PMC7237184 DOI: 10.1016/j.annonc.2020.05.009] [Citation(s) in RCA: 355] [Impact Index Per Article: 88.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Cancer diagnostics and surgery have been disrupted by the response of health care services to the coronavirus disease 2019 (COVID-19) pandemic. Progression of cancers during delay will impact on patients' long-term survival. PATIENTS AND METHODS We generated per-day hazard ratios of cancer progression from observational studies and applied these to age-specific, stage-specific cancer survival for England 2013-2017. We modelled per-patient delay of 3 and 6 months and periods of disruption of 1 and 2 years. Using health care resource costing, we contextualise attributable lives saved and life-years gained (LYGs) from cancer surgery to equivalent volumes of COVID-19 hospitalisations. RESULTS Per year, 94 912 resections for major cancers result in 80 406 long-term survivors and 1 717 051 LYGs. Per-patient delay of 3/6 months would cause attributable death of 4755/10 760 of these individuals with loss of 92 214/208 275 life-years, respectively. For cancer surgery, average LYGs per patient are 18.1 under standard conditions and 17.1/15.9 with a delay of 3/6 months (an average loss of 0.97/2.19 LYGs per patient), respectively. Taking into account health care resource units (HCRUs), surgery results on average per patient in 2.25 resource-adjusted life-years gained (RALYGs) under standard conditions and 2.12/1.97 RALYGs following delay of 3/6 months. For 94 912 hospital COVID-19 admissions, there are 482 022 LYGs requiring 1 052 949 HCRUs. Hospitalisation of community-acquired COVID-19 patients yields on average per patient 5.08 LYG and 0.46 RALYGs. CONCLUSIONS Modest delays in surgery for cancer incur significant impact on survival. Delay of 3/6 months in surgery for incident cancers would mitigate 19%/43% of LYGs, respectively, by hospitalisation of an equivalent volume of admissions for community-acquired COVID-19. This rises to 26%/59%, respectively, when considering RALYGs. To avoid a downstream public health crisis of avoidable cancer deaths, cancer diagnostic and surgical pathways must be maintained at normal throughput, with rapid attention to any backlog already accrued.
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Affiliation(s)
- A Sud
- Division of Genetics and Epidemiology, Institute of Cancer Research, London
| | - M E Jones
- Division of Genetics and Epidemiology, Institute of Cancer Research, London
| | - J Broggio
- National Cancer Registration and Analysis Service, Public Health England, Wellington House, London
| | - C Loveday
- Division of Genetics and Epidemiology, Institute of Cancer Research, London
| | - B Torr
- Division of Genetics and Epidemiology, Institute of Cancer Research, London
| | - A Garrett
- Division of Genetics and Epidemiology, Institute of Cancer Research, London
| | - D L Nicol
- Urology Unit, Royal Marsden NHS Foundation Trust, London
| | - S Jhanji
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden NHS Foundation Trust, London; Division of Cancer Biology, Institute of Cancer Research, London
| | - S A Boyce
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - F Gronthoud
- Department of Microbiology, Royal Marsden NHS Foundation Trust, London
| | - P Ward
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden NHS Foundation Trust, London
| | - J M Handy
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden NHS Foundation Trust, London
| | | | - J Larkin
- Skin and Renal Unit, Royal Marsden NHS Foundation Trust, London; Division of Clinical Studies, Institute of Cancer Research, London
| | - Y-E Suh
- Department of Clinical Oncology, Royal Marsden NHS Foundation Trust, London
| | - S Scott
- RM Partners, West London Cancer Alliance, Royal Marsden NHS Foundation Trust, London
| | - P D P Pharoah
- Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - C Swanton
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London; Cancer Evolution and Genome Instability Laboratory, University College London Cancer Institute, London
| | - C Abbosh
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London; Cancer Evolution and Genome Instability Laboratory, University College London Cancer Institute, London
| | - M Williams
- Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London; Computational Oncology Group, Imperial College London, London
| | - G Lyratzopoulos
- National Cancer Registration and Analysis Service, Public Health England, Wellington House, London; Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, University College London, London
| | - R Houlston
- Division of Genetics and Epidemiology, Institute of Cancer Research, London; Department of Clinical Genetics, Royal Marsden NHS Foundation Trust, London, UK
| | - C Turnbull
- Division of Genetics and Epidemiology, Institute of Cancer Research, London; National Cancer Registration and Analysis Service, Public Health England, Wellington House, London; Department of Clinical Genetics, Royal Marsden NHS Foundation Trust, London, UK.
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26
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Sud A, Torr B, Jones ME, Broggio J, Scott S, Loveday C, Garrett A, Gronthoud F, Nicol DL, Jhanji S, Boyce SA, Williams M, Riboli E, Muller DC, Kipps E, Larkin J, Navani N, Swanton C, Lyratzopoulos G, McFerran E, Lawler M, Houlston R, Turnbull C. Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study. Lancet Oncol 2020; 21:1035-1044. [PMID: 32702311 PMCID: PMC7116538 DOI: 10.1016/s1470-2045(20)30392-2] [Citation(s) in RCA: 302] [Impact Index Per Article: 75.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND During the COVID-19 lockdown, referrals via the 2-week-wait urgent pathway for suspected cancer in England, UK, are reported to have decreased by up to 84%. We aimed to examine the impact of different scenarios of lockdown-accumulated backlog in cancer referrals on cancer survival, and the impact on survival per referred patient due to delayed referral versus risk of death from nosocomial infection with severe acute respiratory syndrome coronavirus 2. METHODS In this modelling study, we used age-stratified and stage-stratified 10-year cancer survival estimates for patients in England, UK, for 20 common tumour types diagnosed in 2008-17 at age 30 years and older from Public Health England. We also used data for cancer diagnoses made via the 2-week-wait referral pathway in 2013-16 from the Cancer Waiting Times system from NHS Digital. We applied per-day hazard ratios (HRs) for cancer progression that we generated from observational studies of delay to treatment. We quantified the annual numbers of cancers at stage I-III diagnosed via the 2-week-wait pathway using 2-week-wait age-specific and stage-specific breakdowns. From these numbers, we estimated the aggregate number of lives and life-years lost in England for per-patient delays of 1-6 months in presentation, diagnosis, or cancer treatment, or a combination of these. We assessed three scenarios of a 3-month period of lockdown during which 25%, 50%, and 75% of the normal monthly volumes of symptomatic patients delayed their presentation until after lockdown. Using referral-to-diagnosis conversion rates and COVID-19 case-fatality rates, we also estimated the survival increment per patient referred. FINDINGS Across England in 2013-16, an average of 6281 patients with stage I-III cancer were diagnosed via the 2-week-wait pathway per month, of whom 1691 (27%) would be predicted to die within 10 years from their disease. Delays in presentation via the 2-week-wait pathway over a 3-month lockdown period (with an average presentational delay of 2 months per patient) would result in 181 additional lives and 3316 life-years lost as a result of a backlog of referrals of 25%, 361 additional lives and 6632 life-years lost for a 50% backlog of referrals, and 542 additional lives and 9948 life-years lost for a 75% backlog in referrals. Compared with all diagnostics for the backlog being done in month 1 after lockdown, additional capacity across months 1-3 would result in 90 additional lives and 1662 live-years lost due to diagnostic delays for the 25% backlog scenario, 183 additional lives and 3362 life-years lost under the 50% backlog scenario, and 276 additional lives and 5075 life-years lost under the 75% backlog scenario. However, a delay in additional diagnostic capacity with provision spread across months 3-8 after lockdown would result in 401 additional lives and 7332 life-years lost due to diagnostic delays under the 25% backlog scenario, 811 additional lives and 14 873 life-years lost under the 50% backlog scenario, and 1231 additional lives and 22 635 life-years lost under the 75% backlog scenario. A 2-month delay in 2-week-wait investigatory referrals results in an estimated loss of between 0·0 and 0·7 life-years per referred patient, depending on age and tumour type. INTERPRETATION Prompt provision of additional capacity to address the backlog of diagnostics will minimise deaths as a result of diagnostic delays that could add to those predicted due to expected presentational delays. Prioritisation of patient groups for whom delay would result in most life-years lost warrants consideration as an option for mitigating the aggregate burden of mortality in patients with cancer. FUNDING None.
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Affiliation(s)
- Amit Sud
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Bethany Torr
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Michael E Jones
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - John Broggio
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | - Stephen Scott
- RM Partners, West London Cancer Alliance, London, UK
| | - Chey Loveday
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Alice Garrett
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Firza Gronthoud
- Microbiology, Royal Marsden NHS Foundation Trust, London, UK
| | - David L Nicol
- Division of Clinical Studies, Institute of Cancer Research, London, UK; Urology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Shaman Jhanji
- Division of Cancer Biology, Institute of Cancer Research, London, UK; Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden NHS Foundation Trust, London, UK
| | - Stephen A Boyce
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matthew Williams
- Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK; Computational Oncology Group, Imperial College London, London, UK
| | - Elio Riboli
- School of Public Health, Imperial College London, London, UK
| | - David C Muller
- School of Public Health, Imperial College London, London, UK
| | - Emma Kipps
- RM Partners, West London Cancer Alliance, London, UK; The Breast Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - James Larkin
- Division of Clinical Studies, Institute of Cancer Research, London, UK; Skin and Renal Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Neal Navani
- Department of Thoracic Medicine, University College London Hospital, London, UK; Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - Charles Swanton
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London, UK; Cancer Evolution and Genome Instability Laboratory, University College London Cancer Institute, London, UK
| | - Georgios Lyratzopoulos
- National Cancer Registration and Analysis Service, Public Health England, London, UK; Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, University College London, London, UK
| | - Ethna McFerran
- Patrick G Johnston Centre for Cancer Research, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Mark Lawler
- Patrick G Johnston Centre for Cancer Research, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK; DATA-CAN, The UK Health Data Research Hub for Cancer, London, UK
| | - Richard Houlston
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK; Department of Clinical Genetics, Royal Marsden NHS Foundation Trust, London, UK
| | - Clare Turnbull
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK; National Cancer Registration and Analysis Service, Public Health England, London, UK; Department of Clinical Genetics, Royal Marsden NHS Foundation Trust, London, UK.
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Magee DJ, Jhanji S, Poulogiannis G, Farquhar-Smith P, Brown MRD. Nonsteroidal anti-inflammatory drugs and pain in cancer patients: a systematic review and reappraisal of the evidence. Br J Anaesth 2019; 123:e412-e423. [PMID: 31122736 DOI: 10.1016/j.bja.2019.02.028] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Emerging data highlights the potential role of cyclooxygenase (COX) inhibitors in the primary prevention of malignancy, reducing metastatic spread and improving overall mortality. Despite nonsteroidal anti-inflammatory drugs (NSAIDs) forming a key component of the WHO analgesic ladder, their use in cancer pain management remains relatively low. This review re-appraises the current evidence regarding the efficacy of COX inhibitors as analgesics in cancer pain, providing a succinct resource to aid clinicians' decision making when determining treatment strategies. METHODS Medline® and Embase® databases were searched for publications up to November 2018. Randomised controlled trials (RCTs) and double-blind controlled studies considering the use of NSAIDs for management of cancer-related pain in adults were included. Animal studies, case reports, and retrospective observational data were excluded. RESULTS Thirty studies investigating the use of NSAIDs in cancer pain management were identified. There is a lack of high-quality evidence regarding the analgesic efficacy of NSAIDs in cancer pain, with short study durations and heterogeneity in outcome measures limiting the ability to draw meaningful conclusions. CONCLUSIONS Despite the renewed interest in these cost-effective, well-established medications in cancer treatment outcomes, there is a paucity of data from the past 15 yr regarding their efficacy in cancer pain management. However, when analgesic strategies in the cancer population are being formulated, it is important that the potential benefits of this class of drug are considered. Further work investigating the role of NSAIDs in cancer pain management is undoubtedly warranted.
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Affiliation(s)
- D J Magee
- Pain Medicine Department, The Royal Marsden Hospital, London, UK; Signalling and Cancer Metabolism, Division of Cancer Biology, The Institute of Cancer Research, London, UK.
| | - S Jhanji
- Anaesthesia and Perioperative Medicine, The Royal Marsden Hospital, London, UK; Perioperative and Critical Care Outcomes Group, Division of Cancer Biology, The Institute of Cancer Research, London, UK
| | - G Poulogiannis
- Signalling and Cancer Metabolism, Division of Cancer Biology, The Institute of Cancer Research, London, UK
| | - P Farquhar-Smith
- Pain Medicine Department, The Royal Marsden Hospital, London, UK
| | - M R D Brown
- Pain Medicine Department, The Royal Marsden Hospital, London, UK; Targeted Approaches to Cancer Pain Group, The Institute of Cancer Research, Sutton, Surrey, UK
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Gardiner MD, Giblin V, Highton D, Jain A, Jeevan R, Jhanji S, Kwasnicki RM, Mosahebi A, Martin D, Sadideen H, Skillman J, Acquaah F, Cato L, Coventry D, Geoghegan L, Iqbal F, Lim D, McCaughey P, Pancholi J, Sinha Y, Stanley G, Twoon M, Berry B, Borelli M, Chan V, Chauhan P, Conci E, Coulson R, Dreyer S, Dynes K, Evans E, Gallagher S, Garner J, Kane T, Lafford G, Mena J, Nguyen U, Nowicka M, Robinson D, Suresh R, Tarassoli SP, Teoh V, Way B. Variation in the perioperative care of women undergoing abdominal-based microvascular breast reconstruction in the United Kingdom (The optiFLAPP Study). J Plast Reconstr Aesthet Surg 2019; 72:35-42. [DOI: 10.1016/j.bjps.2018.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 07/30/2018] [Accepted: 08/19/2018] [Indexed: 11/24/2022]
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Vellinga NAR, Boerma EC, Koopmans M, Donati A, Dubin A, Shapiro NI, Pearse RM, van der Voort PHJ, Dondorp AM, Bafi T, Fries M, Akarsu-Ayazoglu T, Pranskunas A, Hollenberg S, Balestra G, van Iterson M, Sadaka F, Minto G, Aypar U, Hurtado FJ, Martinelli G, Payen D, van Haren F, Holley A, Gomez H, Mehta RL, Rodriguez AH, Ruiz C, Canales HS, Duranteau J, Spronk PE, Jhanji S, Hubble S, Chierego M, Jung C, Martin D, Sorbara C, Bakker J, Ince C. Mildly elevated lactate levels are associated with microcirculatory flow abnormalities and increased mortality: a microSOAP post hoc analysis. Crit Care 2017; 21:255. [PMID: 29047411 PMCID: PMC5646128 DOI: 10.1186/s13054-017-1842-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 09/15/2017] [Indexed: 01/08/2023]
Abstract
Background Mildly elevated lactate levels (i.e., 1–2 mmol/L) are increasingly recognized as a prognostic finding in critically ill patients. One of several possible underlying mechanisms, microcirculatory dysfunction, can be assessed at the bedside using sublingual direct in vivo microscopy. We aimed to evaluate the association between relative hyperlactatemia, microcirculatory flow, and outcome. Methods This study was a predefined subanalysis of a multicenter international point prevalence study on microcirculatory flow abnormalities, the Microcirculatory Shock Occurrence in Acutely ill Patients (microSOAP). Microcirculatory flow abnormalities were assessed with sidestream dark-field imaging. Abnormal microcirculatory flow was defined as a microvascular flow index (MFI) < 2.6. MFI is a semiquantitative score ranging from 0 (no flow) to 3 (continuous flow). Associations between microcirculatory flow abnormalities, single-spot lactate measurements, and outcome were analyzed. Results In 338 of 501 patients, lactate levels were available. For this substudy, all 257 patients with lactate levels ≤ 2 mmol/L (median [IQR] 1.04 [0.80–1.40] mmol/L) were included. Crude ICU mortality increased with each lactate quartile. In a multivariable analysis, a lactate level > 1.5 mmol/L was independently associated with a MFI < 2.6 (OR 2.5, 95% CI 1.1–5.7, P = 0.027). Conclusions In a heterogeneous ICU population, a single-spot mildly elevated lactate level (even within the reference range) was independently associated with increased mortality and microvascular flow abnormalities. In vivo microscopy of the microcirculation may be helpful in discriminating between flow- and non-flow-related causes of mildly elevated lactate levels. Trial registration ClinicalTrials.gov, NCT01179243. Registered on August 3, 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1842-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Namkje A R Vellinga
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands. .,Department of Intensive Care, Medical Center Leeuwarden, P.O. Box 888, 8901 BR, Leeuwarden, The Netherlands.
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, P.O. Box 888, 8901 BR, Leeuwarden, The Netherlands
| | - Matty Koopmans
- Department of Intensive Care, Medical Center Leeuwarden, P.O. Box 888, 8901 BR, Leeuwarden, The Netherlands
| | - Abele Donati
- Department of Biomedical Science and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Arnaldo Dubin
- Sanatorio Otamendi y Miroli, Servicio de Terapia Intensiva, Azcuénaga 870, Buenos Aires, Argentina
| | - Nathan I Shapiro
- Department of Emergency Medicine and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rupert M Pearse
- Barts and The London School of Medicine and Dentistry, London, UK
| | | | - Arjen M Dondorp
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Tony Bafi
- Dor e Terapia Intensiva, Universidade Federal de São Paolo, São Paolo, Brasil
| | - Michael Fries
- Department of Anesthesia and Surgical Intensive Care, St. Vincenz Krankenhaus, Limburg, Germany
| | - Tulin Akarsu-Ayazoglu
- S.B. Medeniyet University Göztepe Education and Research Hospital Kadıköy, Istanbul, Turkey
| | - Andrius Pranskunas
- Intensive Care Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Gianmarco Balestra
- Medical Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Mat van Iterson
- Department of Anesthesiology, Intensive Care and Pain Management, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Farid Sadaka
- Critical Care Medicine/Neurocritical Care, Mercy Hospital St. Louis, St. Louis University Hospital, St. Louis, MO, USA
| | - Gary Minto
- Derriford Hospital, Plymouth University Peninsula School of Medicine, Plymouth, UK
| | - Ulku Aypar
- Intensive Care Unit, Hacettepe University, Ankara, Turkey
| | - F Javier Hurtado
- Intensive Care Unit, Hospital Español-State Health Administration Service, School of Medicine, University of the Republic, Montevideo, Uruguay
| | - Giampaolo Martinelli
- Department of Perioperative Medicine, Barts Heart Centre, St. Bartholomew's Hospital, London, UK
| | - Didier Payen
- Department of Anesthesiology, Critical Care and Mobile Emergency and Resuscitation Service (SMUR), Hôpital Lariboisière Assistance Publique - Hôpitaux de Paris (AP-HP)/Université Paris 7 Diderot, Paris, France
| | | | - Anthony Holley
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - Hernando Gomez
- Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ravindra L Mehta
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | | | - Carolina Ruiz
- Departamento de Medicina Intensiva, Escuela de Medicina, Facultad de Medicina, Universidad Católica de Chile, Santiago, Chile
| | | | - Jacques Duranteau
- Departement d'Anesthesie-Reanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre Assistance Publique - Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, Paris, France
| | - Peter E Spronk
- Intensive Care Unit, Gelre Ziekenhuizen, Apeldoorn, The Netherlands
| | - Shaman Jhanji
- Intensive Care Unit, The Royal Marsden Hospital, London, UK
| | - Sheena Hubble
- Intensive Care Unit, Royal Devon and Exeter Hospital, Exeter, UK
| | | | - Christian Jung
- Department of Cardiology, Universitätsherzzentrum Thüringen, Clinic of Internal Medicine I, Friedrich Schiller University Jena, Jena, Germany.,Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - Daniel Martin
- Intensive Care Unit, Royal Free Hospital, London, UK
| | - Carlo Sorbara
- Dipartimento di Anestesia, Rianimazione e Terapia Intensiva, Azienda Unità Locale Socio Sanitaria 9 (ULSS 9) Veneto, Treviso, Italy
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Kasivisvanathan R, Jhanji S, Waller J, McLeod A, Rao Baikady R, Wigmore T, Gruber P. High risk multi-disciplinary process for major cancer surgery. Br J Anaesth 2016; 117:678-679. [DOI: 10.1093/bja/aew326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Kasivisvanathan R, Abbassi-Ghadi N, McLeod ADM, Oliver A, Rao Baikady R, Jhanji S, Cone S, Wigmore T. Cardiopulmonary exercise testing for predicting postoperative morbidity in patients undergoing hepatic resection surgery. HPB (Oxford) 2015; 17:637-43. [PMID: 25994624 PMCID: PMC4474512 DOI: 10.1111/hpb.12420] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/23/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Cardiopulmonary exercise testing (CPET) may predict which patients are at risk for adverse outcomes after major abdominal surgery. The primary aim of this study was to determine whether CPET variables are predicative of morbidity. METHODS High-risk patients undergoing elective, one-stage, open hepatic resection were preoperatively assessed using CPET. Morbidity, as defined by the Postoperative Morbidity Survey (POMS), was assessed on postoperative day 3. RESULTS A total of 104 patients underwent preoperative CPET and were included in the analysis. Of these, 73 patients (70.2%) experienced postoperative morbidity. Oxygen consumption at anaerobic threshold (V˙O2 at AT, ml/kg/min) was the only CPET predictor of postoperative morbidity on multivariable analysis, with an area under the curve (AUC) of 0.66 [95% confidence interval (CI) 0.55-0.76]. In patients requiring a major hepatic resection (three or more segments), a V˙O2 at AT of <10.2 ml/kg/min gave an AUC of 0.79 (95% CI 0.68-0.86) with 83.9% sensitivity and 52.0% specificity, 80.6% positive predictive value and 62.5% negative predictive value. CONCLUSIONS The application of a cut-off value for V˙O2 at AT of <10.2 ml/kg/min in patients undergoing major hepatic resection may be useful for predicting which patients will experience morbidity.
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Affiliation(s)
| | - Nima Abbassi-Ghadi
- Department of Surgery and Cancer, Imperial College London, St Mary's HospitalLondon, UK
| | - Andrew D M McLeod
- Department of Anaesthesia and Critical Care, The Royal MarsdenLondon, UK
| | - Alex Oliver
- Department of Anaesthesia and Critical Care, The Royal MarsdenLondon, UK
| | | | - Shaman Jhanji
- Department of Anaesthesia and Critical Care, The Royal MarsdenLondon, UK
| | - Stephen Cone
- Department of Anaesthesia, University College London HospitalsLondon, UK
| | - Timothy Wigmore
- Department of Anaesthesia and Critical Care, The Royal MarsdenLondon, UK
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Cullen MR, Jhanji S, Pearse RM, Fitzgibbon MC. Neutrophil gelatinase-associated lipocalin and albuminuria as predictors of acute kidney injury in patients treated with goal-directed haemodynamic therapy after major abdominal surgery. Ann Clin Biochem 2013; 51:392-9. [PMID: 24123926 DOI: 10.1177/0004563213507438] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Neutrophil gelatinase-associated lipocalin (NGAL) is emerging as a new biomarker for the early identification of acute kidney injury (AKI). There is also increasing evidence of an association between urinary albumin/creatinine ratio (ACR) and AKI. The primary aim of this study was to evaluate the clinical utility of these biomarkers to predict AKI in a population of perioperative patients treated with goal-directed haemodynamic therapy (GDHT). Secondary aims were to examine NGAL and ACR as sensitive biomarkers to detect the effects of GDHT and to investigate the association of these biomarkers with secondary outcomes. METHODS Urine was obtained from 109 patients admitted to a critical care unit following major abdominal surgery. Patients were treated with intravenous fluid, GDHT with intravenous fluid or GDHT with intravenous fluid and dopexamine. Urine was collected preoperatively, and at times 0, 8 and 24 h postoperatively and outcome monitored for 28 days. RESULTS There were no significant differences in NGAL or ACR concentrations between the cohorts treated with GDHT compared to standard care. However, both biomarker concentrations rose significantly in all cohorts over the time points. There were no significant differences in NGAL observed between patients who developed AKI and those who did not. However, there were significantly higher ACR preoperatively in patients who developed AKI. There were higher NGAL concentrations in patients who developed an infection and who died. CONCLUSIONS NGAL has a poor predictive role in evaluating AKI in this clinical setting. Preoperative ACR may have a role as an AKI marker.
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Affiliation(s)
- M R Cullen
- Department of Clinical Biochemistry and Diagnostic Endocrinology, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
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Gillies MA, Habicher M, Jhanji S, Sander M, Mythen M, Hamilton M, Pearse RM. Incidence of postoperative death and acute kidney injury associated with i.v. 6% hydroxyethyl starch use: systematic review and meta-analysis. Br J Anaesth 2013; 112:25-34. [PMID: 24046292 DOI: 10.1093/bja/aet303] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Trials suggest that the use of i.v. hydroxyethyl starch (HES) solutions is associ-ated with increased risk of death and acute kidney injury (AKI) in critically ill patients. It is uncertain whether similar adverse effects occur in surgical patients. METHODS Systematic review and meta-analysis of trials in which patients were randomly allocated to 6% HES solutions or alternative i.v. fluids in patients undergoing surgery. Ovid Medline, Embase, Cinhal, and Cochrane Database of Systematic Reviews were searched for trials comparing 6% HES with clinically relevant non-starch comparator. The primary end-point was hospital mortality. Secondary endpoints were requirement for renal replacement therapy (RRT) and author-defined AKI. Pre-defined subgroups were cardiac and non-cardiac surgery. RESULTS Four hundred and fifty-six papers were identified; of which 19 met the inclusion criteria. In total, 1567 patients were included in the analysis. Dichotomous outcomes were expressed as a difference of proportions [risk difference (RD)]. There was no difference in hospital mortality [RD 0.00, 95% confidence interval (CI) -0.02, 0.02], requirement for RRT (RD -0.01, 95% CI -0.04, 0.02), or AKI (RD 0.02, 95% CI -0.02 to 0.06) between compared arms overall or in predefined subgroups. CONCLUSIONS We did not identify any differences in the incidence of death or AKI in surgical patients receiving 6% HES. Included studies were small with low event rates and low risk of heterogeneity. Narrow CIs suggest that these findings are valid. Given the absence of demonstrable benefit, we are unable to recommend the use of 6% HES solution in surgical patients.
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Affiliation(s)
- M A Gillies
- Department of Critical Care, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK
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Reynolds T, Vivian-Smith A, Jhanji S, Pearse RM. Observational study of the effects of age, diabetes mellitus, cirrhosis and chronic kidney disease on sublingual microvascular flow. Perioper Med (Lond) 2013; 2:7. [PMID: 24472121 PMCID: PMC3964336 DOI: 10.1186/2047-0525-2-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 03/15/2013] [Indexed: 12/02/2022] Open
Abstract
Background Sidestream dark field (SDF) imaging has been used to demonstrate microcirculatory abnormalities in a variety of critical illnesses. The microcirculation is also affected by advancing age and chronic comorbidities. However, the effect of these conditions on SDF microcirculatory parameters has not been well described. Methods SDF images were obtained from five groups of 20 participants: healthy volunteers under the age of 25, healthy volunteers over the age of 55, and clinic patients over the age of 55 with one of diabetes mellitus, cirrhosis and stage 5 chronic kidney disease. Microcirculatory parameters between the groups were then compared for significance using analysis of variance for parametric and the Kruskal-Wallis test for non-parametric data. Results Median microvascular flow index was 2.85 (interquartile range 2.75 to 3.0) for participants aged <25, 2.81 (2.66 to 2.97) for those aged >55, 2.88 (2.75 to 3.0) for those with diabetes mellitus, 3.0 (2.83 to 3.0) for those with cirrhosis and 3.0 (2.78 to 3.0) for those with chronic kidney disease (P for difference between groups = 0.14). Similarly, there were no significant differences in the proportion of perfused vessels and perfused vessel density between the groups. Conclusions Older age, diabetes, and chronic kidney and liver disease need not be considered confounding factors for comparison of SDF microcirculatory parameters in the critically ill.
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Affiliation(s)
| | | | | | - Rupert M Pearse
- Barts and The London School of Medicine and Dentistry, Queen Mary's University of London, Turner Street, London E1 2AD, UK.
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Reynolds T, Jhanji S, Vivian-Smith A, Pearse RM. Observational study of the effects of age, diabetes mellitus, cirrhosis and chronic kidney disease on sublingual microvascular flow. Crit Care 2013. [PMCID: PMC3642591 DOI: 10.1186/cc12153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Jhanji S, Vivian-Smith A, Lucena-Amaro S, Watson D, Hinds CJ, Pearse RM. Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial. Crit Care 2010; 14:R151. [PMID: 20698956 PMCID: PMC2945135 DOI: 10.1186/cc9220] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Accepted: 08/10/2010] [Indexed: 12/26/2022]
Abstract
Introduction Post-operative outcomes may be improved by the use of flow related end-points for intra-venous fluid and/or low dose inotropic therapy. The mechanisms underlying this benefit remain uncertain. The objective of this study was to assess the effects of stroke volume guided intra-venous fluid and low dose dopexamine on tissue microvascular flow and oxygenation and inflammatory markers in patients undergoing major gastrointestinal surgery. Methods Randomised, controlled, single blind study of patients admitted to a university hospital critical care unit following major gastrointestinal surgery. For eight hours after surgery, intra-venous fluid therapy was guided by measurements of central venous pressure (CVP group), or stroke volume (SV group). In a third group stroke volume guided fluid therapy was combined with dopexamine (0.5 mcg/kg/min) (SV & DPX group). Results 135 patients were recruited (n = 45 per group). In the SV & DPX group, increased global oxygen delivery was associated with improved sublingual (P < 0.05) and cutaneous microvascular flow (P < 0.005) (sublingual microscopy and laser Doppler flowmetry). Microvascular flow remained constant in the SV group but deteriorated in the CVP group (P < 0.05). Cutaneous tissue oxygen partial pressure (PtO2) (Clark electrode) improved only in the SV & DPX group (P < 0.001). There were no differences in serum inflammatory markers. There were no differences in overall complication rates between the groups although acute kidney injury was more frequent in the CVP group (CVP group ten patients (22%); pooled SV and SV & DPX groups seven patients (8%); P = 0.03) (post hoc analysis). Conclusions Stroke volume guided fluid and low dose inotropic therapy was associated with improved global oxygen delivery, microvascular flow and tissue oxygenation but no differences in the inflammatory response to surgery. These observations may explain improved clinical outcomes associated with this treatment in previous trials. Trial registration number ISRCTN 94850719
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Affiliation(s)
- Shaman Jhanji
- Barts and The London School of Medicine and Dentistry, Queen Mary's University of London, Turner Street, London E1 2AD, UK.
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Jhanji S, Thomas B, Ely A, Watson D, Hinds CJ, Pearse RM. Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large NHS trust. Anaesthesia 2008; 63:695-700. [PMID: 18489613 DOI: 10.1111/j.1365-2044.2008.05560.x] [Citation(s) in RCA: 180] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Previous reports describe a population of non-cardiac surgical patients at high risk of complications and death. Outcomes are sub-optimal for such patients, perhaps in part related to inadequate provision or ineffective utilisation of critical care resources. In this study, data describing 26,051 in-patient non-cardiac surgical procedures performed in a large NHS Trust between April 2002 and March 2005 were extracted from local databases. Of these procedures, 2 414 (9.3%) were high risk with an overall mortality rate of 12.2% and a prolonged hospital stay (high-risk population median (IQR) 16 (9-30) days vs standard risk 3 (2-6) days). Mortality rates for specific procedures were consistent with UK averages. However, only 852 (35.3%) high-risk patients were admitted to a critical care unit at any stage after surgery. Of 294 high-risk patients who died, only 144 (49.0%) were admitted to a critical care unit at any time and only 75 (25.6%) of these deaths occurred within a critical care area. Mortality rates were high amongst patients discharged and readmitted to critical care (37.7%) and amongst those admitted to critical care following initial postoperative care on a standard ward (29.9%). These data suggest that the outcome of high-risk general surgical patients could be improved by adequate provision and more effective utilisation of critical care resources.
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Affiliation(s)
- S Jhanji
- Barts and The London School of Medicine and Dentistry, London, UK
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