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Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial. Lancet Diabetes Endocrinol 2024; 12:39-50. [PMID: 38061371 PMCID: PMC7615591 DOI: 10.1016/s2213-8587(23)00321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001). INTERPRETATION Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor. FUNDING Boehringer Ingelheim and Eli Lilly.
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Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial. Lancet Diabetes Endocrinol 2024; 12:51-60. [PMID: 38061372 DOI: 10.1016/s2213-8587(23)00322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). INTERPRETATION In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. FUNDING Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.
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Abstract
Current methods for tuberculosis treatment monitoring are suboptimal. We evaluated plasma matrix metalloproteinase (MMP) and procollagen III N-terminal propeptide concentrations before and during tuberculosis treatment as biomarkers. Plasma MMP-1, MMP-8, and MMP-10 concentrations significantly decreased during treatment. Plasma MMP-8 was increased in sputum Mycobacterium tuberculosis culture–positive relative to culture-negative participants, before (median, 4993 pg/mL [interquartile range, 2542–9188] vs 698 [218–4060] pg/mL, respectively; P = .004) and after (3650 [1214–3888] vs 720 [551–1321] pg/mL; P = .008) 6 months of tuberculosis treatment. Consequently, plasma MMP-8 is a potential biomarker to enhance tuberculosis treatment monitoring and screen for possible culture positivity.
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Topic: AS06-Prognosis/AS06a-Prognostic factors of outcome and risk assessment. Leuk Res 2021. [DOI: 10.1016/j.leukres.2021.106679.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Optimal strategies for monitoring lipid levels in patients at risk or with cardiovascular disease: a systematic review with statistical and cost-effectiveness modelling. Health Technol Assess 2016; 19:1-401, vii-viii. [PMID: 26680162 DOI: 10.3310/hta191000] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Various lipid measurements in monitoring/screening programmes can be used, alone or in cardiovascular risk scores, to guide treatment for prevention of cardiovascular disease (CVD). Because some changes in lipids are due to variability rather than true change, the value of lipid-monitoring strategies needs evaluation. OBJECTIVE To determine clinical value and cost-effectiveness of different monitoring intervals and different lipid measures for primary and secondary prevention of CVD. DATA SOURCES We searched databases and clinical trials registers from 2007 (including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Clinical Trials Register, the Current Controlled Trials register, and the Cumulative Index to Nursing and Allied Health Literature) to update and extend previous systematic reviews. Patient-level data from the Clinical Practice Research Datalink and St Luke's Hospital, Japan, were used in statistical modelling. Utilities and health-care costs were drawn from the literature. METHODS In two meta-analyses, we used prospective studies to examine associations of lipids with CVD and mortality, and randomised controlled trials to estimate lipid-lowering effects of atorvastatin doses. Patient-level data were used to estimate progression and variability of lipid measurements over time, and hence to model lipid-monitoring strategies. Results are expressed as rates of true-/false-positive and true-/false-negative tests for high lipid or high CVD risk. We estimated incremental costs per quality-adjusted life-year. RESULTS A total of 115 publications reported strength of association between different lipid measures and CVD events in 138 data sets. The summary adjusted hazard ratio per standard deviation of total cholesterol (TC) to high-density lipoprotein (HDL) cholesterol ratio was 1.25 (95% confidence interval 1.15 to 1.35) for CVD in a primary prevention population but heterogeneity was high (I(2) = 98%); similar results were observed for non-HDL cholesterol, apolipoprotein B and other ratio measures. Associations were smaller for other single lipid measures. Across 10 trials, low-dose atorvastatin (10 and 20 mg) effects ranged from a TC reduction of 0.92 mmol/l to 2.07 mmol/l, and low-density lipoprotein reduction of between 0.88 mmol/l and 1.86 mmol/l. Effects of 40 mg and 80 mg were reported by one trial each. For primary prevention, over a 3-year period, we estimate annual monitoring would unnecessarily treat 9 per 1000 more men (28 vs. 19 per 1000) and 5 per 1000 more women (17 vs. 12 per 1000) than monitoring every 3 years. However, annual monitoring would also undertreat 9 per 1000 fewer men (7 vs. 16 per 1000) and 4 per 1000 fewer women (7 vs. 11 per 1000) than monitoring at 3-year intervals. For secondary prevention, over a 3-year period, annual monitoring would increase unnecessary treatment changes by 66 per 1000 men and 31 per 1000 women, and decrease undertreatment by 29 per 1000 men and 28 per 1000 men, compared with monitoring every 3 years. In cost-effectiveness, strategies with increased screening/monitoring dominate. Exploratory analyses found that any unknown harms of statins would need utility decrements as large as 0.08 (men) to 0.11 (women) per statin user to reverse this finding in primary prevention. LIMITATION Heterogeneity in meta-analyses. CONCLUSIONS While acknowledging known and potential unknown harms of statins, we find that more frequent monitoring strategies are cost-effective compared with others. Regular lipid monitoring in those with and without CVD is likely to be beneficial to patients and to the health service. Future research should include trials of the benefits and harms of atorvastatin 40 and 80 mg, large-scale surveillance of statin safety, and investigation of the effect of monitoring on medication adherence. STUDY REGISTRATION This study is registered as PROSPERO CRD42013003727. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Contraception in Japan: Current trends. Contraception 2016; 93:475-7. [PMID: 26872717 DOI: 10.1016/j.contraception.2016.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/01/2016] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES High proportion of Japanese uses condoms; lower proportion uses oral contraceptive pills (OCPs). We examined the longitudinal patterns for contraceptive usage in Japan and evaluated differences before and after OCP government approval. STUDY DESIGN We accessed nationally representative survey data for women aged 16-49years from 1950 to 2014. RESULTS Usage of condoms and OCP was 83.4% and 3.0%, respectively in 2014. OCP use before (1.21%) and after (1.97%) government approval did not differ significantly (p=.58). CONCLUSIONS The prevalence of OCP usage remains low in Japan. A wide gap in use between Japan and other developed countries exists. IMPLICATIONS Through a wide gap in OCP use between Japan and other countries, we revealed how choices of contraceptive methods and their benefits could be openly available for women of reproductive age, and how health care professionals disseminate appropriate knowledge about contraception for women in need.
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Abstract
On the 50th anniversary of Norman Geschwind's seminal paper entitled ‘Disconnexion syndrome in animal and man’, we pay tribute to his ideas by applying contemporary tractography methods to understand white matter disconnection in 3 classic cases that made history in behavioral neurology. We first documented the locus and extent of the brain lesion from the computerized tomography of Phineas Gage's skull and the magnetic resonance images of Louis Victor Leborgne's brain, Broca's first patient, and Henry Gustave Molaison. We then applied the reconstructed lesions to an atlas of white matter connections obtained from diffusion tractography of 129 healthy adults. Our results showed that in all 3 patients, disruption extended to connections projecting to areas distant from the lesion. We confirmed that the damaged tracts link areas that in contemporary neuroscience are considered functionally engaged for tasks related to emotion and decision-making (Gage), language production (Leborgne), and declarative memory (Molaison). Our findings suggest that even historic cases should be reappraised within a disconnection framework whose principles were plainly established by the associationist schools in the last 2 centuries.
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90 * PREDICTORS OF ALL-CAUSE MORTALITY IN ELDERLY PATIENTS WITH STAGES 3-4 CHRONIC KIDNEY DISEASE. Age Ageing 2014. [DOI: 10.1093/ageing/afu039.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pan-atlantic analysis of the overlap of a highly migratory species, the leatherback turtle, with pelagic longline fisheries. Proc Biol Sci 2014; 281:20133065. [PMID: 24523271 PMCID: PMC4027393 DOI: 10.1098/rspb.2013.3065] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Large oceanic migrants play important roles in ecosystems, yet many species are of conservation concern as a result of anthropogenic threats, of which incidental capture by fisheries is frequently identified. The last large populations of the leatherback turtle, Dermochelys coriacea, occur in the Atlantic Ocean, but interactions with industrial fisheries could jeopardize recent positive population trends, making bycatch mitigation a priority. Here, we perform the first pan-Atlantic analysis of spatio-temporal distribution of the leatherback turtle and ascertain overlap with longline fishing effort. Data suggest that the Atlantic probably consists of two regional management units: northern and southern (the latter including turtles breeding in South Africa). Although turtles and fisheries show highly diverse distributions, we highlight nine areas of high susceptibility to potential bycatch (four in the northern Atlantic and five in the southern/equatorial Atlantic) that are worthy of further targeted investigation and mitigation. These are reinforced by reports of leatherback bycatch at eight of these sites. International collaborative efforts are needed, especially from nations hosting regions where susceptibility to bycatch is likely to be high within their exclusive economic zone (northern Atlantic: Cape Verde, Gambia, Guinea Bissau, Mauritania, Senegal, Spain, USA and Western Sahara; southern Atlantic: Angola, Brazil, Namibia and UK) and from nations fishing in these high-susceptibility areas, including those located in international waters.
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HIV control through a single nucleotide on the HLA-I locus. Retrovirology 2012. [PMCID: PMC3441525 DOI: 10.1186/1742-4690-9-s2-o47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Can leopards change their spots? Br J Radiol 2010; 83:991-2. [DOI: 10.1259/bjr/18427837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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P09-18. Cw*0303/0304 HIV specific CTL response toward GagYL9 select for HIV escape variants with low fitness that is compensated by intra-codon variation. Retrovirology 2009. [PMCID: PMC2767617 DOI: 10.1186/1742-4690-6-s3-p131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Relationship between point gene mutation, chromosomal abnormality, and tumour suppressor gene methylation status in colorectal adenomas. J Pathol 2006; 210:344-50. [PMID: 16902913 DOI: 10.1002/path.2044] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Epigenetic mechanisms in carcinogenesis may have a significant role in the development of colorectal cancer. To investigate this phenomenon in early-stage disease, promoter methylation status in the tumour suppressor genes APC, MGMT, hMLH1, P14/P14ARF, and CDKN2A/P16 was investigated in 78 colorectal adenomas. These had previously been characterized for mutations of APC, KRAS, and TP53 genes and for chromosomal abnormality by comparative genomic hybridization (CGH). APC hypermethylation was seen in 52 tumours (66.7%). APC showed either methylation or mutation in 66 lesions (84.6%), but these events were not statistically associated. MGMT methylation was detected in 39 cases (50%). Adenomas with this abnormality showed a significantly lower number of chromosomal changes by CGH (p < 0.02), confirming that DNA repair defect of this type is associated with a lower level of chromosomal instability. An hMLH1 methylation defect was seen in only one adenoma (1.3%), from a patient who had a synchronous cancer showing the same defect. Methylation of P14 (P14ARF) was seen in 31 adenomas (39.7%) and CDKN2A (P16) abnormality in 25 (32.1%). DNA methylation at two or more loci was seen in 46 tumours (59%), while 11 lesions (14.1%) showed no evidence of hypermethylation at any of the loci studied. Methylation at any or all of MGMT, P14 or P16 was significantly associated with APC methylation (p = 0.01). Those neoplasms with more than two methylated genes showed significantly fewer chromosomal abnormalities than adenomas with one or no methylated loci (p < 0.001). There was no association between specific individual chromosomal abnormalities, APC, KRAS or TP53 mutations and any pattern of methylation abnormality. We conclude that methylation abnormality is very common in pre-invasive colorectal neoplasia, and that high level methylation is associated with low level chromosomal instability.
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Thyroid isthmusectomy: a critical appraisal. The Journal of Laryngology & Otology 2006; 121:986-9. [PMID: 17156579 DOI: 10.1017/s0022215106005238] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/03/2006] [Indexed: 11/06/2022]
Abstract
Thyroid lobectomy with isthmusectomy is the standard surgical technique for removal of unilateral thyroid nodules, and it involves the exposure of the tracheoesophageal grooves. Thyroid isthmusectomy is a surgical procedure that excises only the thyroid isthmus. It allows excision of a lesion without the exposure of the tracheoesophageal grooves.We aimed to demonstrate that isthmusectomy could be a safe alternative to thyroid lobectomy with isthmusectomy in patients with nodules confined to the isthmus or the pyramidal lobe.This was a prospective study performed over a five year period from 1999 to 2004. Inclusion criteria for thyroid isthmusectomy were: patients with a single lesion located in the region of the thyroid isthmus or the pyramidal lobe; maximum lesion diameter of 30 mm; and cytological reports of non-diagnostic appearance, follicular cells or suspicion of malignancy.Nine patients were identified with these criteria. Histology included two colloid nodules, three benign follicular adenomas, two Hurthle cell adenomas and two papillary thyroid carcinomas. There were no recorded complications.Thyroid isthmusectomy is a safe alternative to thyroid lobectomy with isthmusectomy in patients who have nodules confined to the isthmus and pyramidal lobe. Leaving a cuff of normal thyroid tissue has the advantage of not exposing the tracheoesophageal grooves, thus minimising potential damage to the recurrent laryngeal nerves and parathyroids. Surgeons performing isthmusectomies should be experienced in more complex thyroid surgical procedures.
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Automation of MX data collection and processing. Acta Crystallogr A 2005. [DOI: 10.1107/s0108767305094055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Lower gastrointestinal symptoms are not predictive of colorectal neoplasia in a faecal occult blood screen-positive population. Br J Surg 2005; 92:478-81. [PMID: 15609377 DOI: 10.1002/bjs.4879] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the incidence of lower gastrointestinal symptoms in faecal occult blood (FOB) test-positive participants in a colorectal screening programme, and to compare the colonoscopic findings in symptomatic and asymptomatic individuals. METHODS Five hundred and sixty-three consecutive individuals with a positive FOB test in the Scottish arm of the national colorectal cancer screening pilot were studied. All were aged between 50 and 69 years and underwent colonoscopy. Before the procedure the participants were given a standard questionnaire to elicit gastrointestinal symptoms; these were correlated with the colonoscopic findings. RESULTS Of the 563 participants, 439 (78.0 per cent) had one or more lower gastrointestinal symptoms and 124 (22.0 per cent) were symptom free. Taking adenoma and carcinoma together, 322 (57.2 per cent) of the subjects were found to have colorectal neoplasia, and 128 (22.7 per cent) had a completely normal colon. Rectal bleeding was the most common symptom, followed by change in bowel habit, abdominal pain, tenesmus, unexplained weight loss, rectal pain and unexplained anaemia. No significant associations were found between any of these symptoms and the findings at colonoscopy. CONCLUSION In a FOB test-positive screened population, lower gastrointestinal symptoms are common, but are not predictive of colorectal neoplasia.
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Abstract
AIMS The aim of a critical care outreach team is to facilitate discharges from critical care beds, educate ward staff in the management of deteriorating patients, facilitate transfer to critical care and reduce readmission rates to critical care. Although intuitively a good idea, there are few data to support outreach in terms of reducing the readmission rate to critical care and subsequent patient mortality. This retrospective observational study attempted to determine the change in the critical care readmission rate, an indicator of the quality of critical care, critical care mortality and in-hospital mortality following the introduction of a critical care outreach team in a major teaching hospital. METHODS A retrospective review of 1380 discharges from critical care was undertaken and the readmissions identified (n = 176). Readmission rate, mortality and other demographic data were compared between the pre and post-outreach periods. RESULTS Critical care mortality, in-hospital mortality and 30-day mortality were all reduced in the post-outreach period amongst readmissions to critical care. There was also a decease in the overall mortality of all patients admitted to critical care. There were no apparent causative factors for this reduction in mortality before and following outreach. CONCLUSIONS There are many confounding factors in assessing the impact of outreach teams in hospitals. This study tentatively concludes that outreach teams may have a favourable impact on mortality rate amongst readmissions to critical care, but more data is needed from multicentre trials.
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Abstract
Services for neonatal intensive care in the United Kingdom have evolved in a largely unplanned fashion. Units of different sizes provide various amounts of intensive care, and, with a few exceptions, there is little or no formal regional or subregional organisation. Chronic underresourcing and the salvaging of ever more complex infants have resulted in tertiary neonatal intensive care units operating at full capacity most of the time, a situation compounded by a chronic national shortage of nursing staff. These factors have in turn resulted in an increase in requirements for emergency perinatal transfers.
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Benign complications of expandable metal stents used in the palliation of oesophageal carcinoma: two case reports. Br J Radiol 2004; 77:245-7. [PMID: 15020368 DOI: 10.1259/bjr/32883350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We describe two patients who were treated with self-expanding metal stent (SEMS) insertion as palliation of malignant oesophageal strictures. Both patients re-presented with dysphagia several months after SEMS insertion due to benign strictures. Initial treatment with balloon dilation and medical management had limited success so both patients had further SEMS inserted across the secondary benign strictures. This provided very good symptomatic relief. Chemotherapy and chemo-radiation in patients with inoperable oesophageal carcinoma are prolonging patient survival. As patients survival lengthens benign complications of SEMS may become an increasing clinical problem.
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Abstract
OBJECTIVE To evaluate the safety and practicality of using advanced neonatal nurse practitioners (ANNPs) to lead acute neonatal transfers. DESIGN Comparison of transport times, transport interventions, and physiological variables, covering the first four complete years of operating a transport service that uses ANNPs and specialist paediatric registrars (SpRs) interchangeably. SETTING Tertiary neonatal transport service. PATIENTS The first 51 transfers of sick infants under 28 days of age by an ANNP led transport team into Nottingham compared with the next consecutive SpR led transfer after each ANNP led one. MAIN OUTCOME MEASURES Transport times; interventions and support given during stabilisation for transfer and during transfer; condition on completion of transfer, assessed from blood glucose, systolic blood pressure, pH, oxygenation, and temperature. RESULTS The ANNP led team responded more rapidly to requests for transfer and took longer to stabilise babies. The groups undertook similar numbers of procedures during stabilisation, and there were no differences in the ventilatory and other support that infants needed in transit. The infants transferred by the doctor led group had worse values for pH (doctor led, 7.31 (6.50-7.46); ANNP led, 7.35 (7.04-7.50), p = 0.02) and PaO(2) (doctor led, 6.7 (2.4-13.1); ANNP led, 8.7 (3.5-17.0); p = 0.008) before transfer (all values median (range)). Comparisons of the infant's condition before and after transfer showed a significant improvement in temperature for the infants transferred by ANNP led teams (36.8 degrees C (34.0-37.8) v 37.0 degrees C (34.6-38.0), p = 0.001) and in oxygen saturation (96% (88-100) v 98% (92-100), p = 0.01). There were no differences between the ANNP and doctor led groups in the values obtained for any variable after transfer. CONCLUSIONS Clinical condition on completion of transport is similar for babies transferred by ANNP and doctor led teams. ANNP led transport appears to be practical and safe.
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Abstract
BACKGROUND The single-layer appositional serosubmucosal anastomosis is a well established technique and appears to have a favourable record. Over a 15-year period the senior author of this paper has performed or directly supervised 553 anastomoses using this technique. This report describes the results of these operations, the results of stapled anastomoses carried out during the same period and discusses the utility of the handsewn technique. METHODS From August 1986 to July 2001, 553 intestinal anastomoses in 550 patients were fashioned using single-layer, interrupted serosubmucosal 3/0 braided polyamide and 131 anastomoses in 131 patients were performed using a circular anastomosing stapler. RESULTS One anastomotic leakage occurred in the group of patients whose anastomosis was handsewn (0.2%) and 11 leaks occurred in those who had a stapled anastomoses (8.4%). The mortality rate in each group was similar (2% and 2.3%, respectively). There were no deaths attributable to anastomotic dehiscence in either group. CONCLUSION In this prospectively audited series of 553 handsewn anastomoses the leakage rate was 0.2%. These results compare favourably with other published series and continue to support a single layer of interrupted serosubmucosal sutures as the gold standard for anastomoses involving the large or small bowel.
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Abstract
Colorectal cancer is the second most common cause of cancer death in the UK. Prompt investigation of suspicious symptoms is important, but there is increasing evidence that screening for the disease can produce significant reductions in mortality. High quality surgery is of paramount importance in achieving good outcomes, particularly in rectal cancer, but adjuvant radiotherapy and chemotherapy have important parts to play. The treatment of advanced disease is still essentially palliative, although surgery for limited hepatic metastases may be curative in a small proportion of patients.
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Abstract
BACKGROUND It is widely accepted that the adenoma-carcinoma sequence represents the process by which most, if not all, colorectal cancers arise. The evidence supporting this hypothesis has increased rapidly in recent years and the purpose of this article is to review this evidence critically and highlight its clinical significance. METHODS Medline searches were used to identify recent key articles relating to the adenoma-carcinoma sequence. Further pertinent articles were obtained by manual scanning of the reference lists of identified papers. RESULTS The evidence supporting the adenoma-carcinoma sequence can be classified as epidemiological, clinicopathological and genetic. The most recent and largest body of data relates to molecular genetic events and their cellular effects; however, many other approaches, such as cytogenetics, molecular cytogenetics and cytometry, have also yielded valuable information. CONCLUSION Recent work continues to support the adenoma-carcinoma sequence, but there is a paucity of data on the interrelationship between different genetic mutations and on the relationship between molecular and other types of genetic abnormalities. The clinical utility of the observations described has yet to be fully realized and global genetic analysis of colorectal tumours may prove to be central in rational adenoma management.
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Colonoscopy. JOURNAL OF THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH 2002; 47:502-9. [PMID: 12018696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Colonoscopy is now the gold standard method for investigating most colonic symptoms. However, it is a demanding procedure that can be associated with low completion rates and significant complications, and it requires considerable skill to perform colonoscopy consistently well and safely. In this article, the key steps in performing colonoscopy are described with a view to providing the trainee with a logical sequence of manoeuvres on which to base a sound technique.
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Detection of colorectal carcinoma on double contrast barium enema when double reporting is routinely performed: an audit of current practice. Clin Radiol 2002; 57:184-7. [PMID: 11952311 DOI: 10.1053/crad.2001.0832] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the sensitivity of double contrast barium enema (DCBE) in the detection of colorectal carcinoma (CRC) when double reporting is routinely performed. METHOD AND MATERIALS Over a 1-year period all patients with a diagnosis of CRC within a large teaching hospital were identified. Using computer records, any patient with CRC who had had a DCBE within 5 years of diagnosis was identified. During this time period all DCBE were double reported by the radiographer or radiology trainee who performed the enema and by a consultant radiologist specializing in gastrointestinal radiology. RESULTS Over the 1-year period 169 patients were identified with a diagnosis of CRC. Seventy patients had had a DCBE within the preceding 5 years. Sixty-four patients had had CRC diagnosed on the DCBE. One patient had a sessile polyp diagnosed, which was removed at colonoscopy and found to be an invasive adenocarcinoma. In five cases (7%) the CRC was not diagnosed on DCBE. In three cases the lesions could be seen retrospectively, in one case the lesion could not be seen and in one case the examination had been incomplete. CONCLUSION In our series the miss-rate for CRC was 7%. Previous studies have shown miss-rates of 15-24%. These studies have not routinely employed double reporting. Our results suggest that double reporting of DCBE significantly reduces the miss-rate and that this reduction is due to fewer perceptive errors.
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Abstract
The level of error in radiology has been tabulated from articles on error and on "double reporting" or "double reading". The level of error varies depending on the radiological investigation, but the range is 2-20% for clinically significant or major error. The greatest reduction in error rates will come from changes in systems.
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Opportunity for audit: establishing and monitoring the use of protocols for nurse-led treatments of minor injuries. ACCIDENT AND EMERGENCY NURSING 2001; 9:6-13. [PMID: 11760265 DOI: 10.1054/aaen.2000.0183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
During the last three years an integrated initiative has evolved in the casualty units of nine community hospitals in the Grampian region of Scotland. This has involved the development of nurse-led treatments for minor injuries based on a large number of assessment/treatment protocols. This paper describes how this change was used as an opportunity to initiate audit within clinical practice. Methods of auditing the use of the new protocols are detailed and baseline results are reported and discussed. In this way it is hoped that nurses involved in similar developments can learn from the strengths and weaknesses of this initiative.
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Abstract
The aim of the study was to determine whether clinical information alters the CT report. This prospective blinded study consisted of 50 consecutive patients who attended a Department of Radiology for CT. Each study was interpreted by two of three consultant radiologists, before and after knowledge of the clinical information. 19 reports were changed after clinical information was known. Clinical follow-up was available in 15 cases. In ten cases the reports were more accurate after clinical information and in five cases the reports were less accurate. In three of the five cases where accuracy was reduced, the clinical information was incorrect. It was concluded that clinical information affects the CT report. If the information is accurate it has a beneficial effect; if it is inaccurate it has a detrimental effect. The more complex the investigation, the more important the clinical information. There was a correlation between readers regarding the influence of clinical information. Correct clinical information therefore improves the radiology report. It is the responsibility of the clinician to provide this information in an accurate and legible form.
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Who should be performing routine abdominal ultrasound? A prospective double-blind study comparing the accuracy of radiologist and radiographer. Clin Radiol 2000; 55:606-9. [PMID: 10964731 DOI: 10.1053/crad.2000.0491] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To compare the accuracy of radiographers and radiologists in routine abdominal ultrasound. MATERIALS AND METHODS One hundred consecutive patients attending for routine abdominal ultrasound were included. Each patient was examined by both a radiographer and radiologist. Both operators noted their findings and wrote a concluding report without conferring. Reports were compared. Where there was disagreement the patient was either re-examined by another radiologist or had further investigation. RESULTS Of 100 patients, 52 were men and 48 were women. The age range was 19-88 years (median 52 years). Thirty-seven patients had renal tract ultrasound, one had an aortic ultrasound and 62 had general upper abdominal ultrasound. In 44 cases both operators reported the examination as normal. In 49 cases both operators reported the examinations as abnormal and there was complete agreement between the operators. In seven cases there was not complete agreement between operators. Three of these disagreements were considered minor and four major. In three of the seven cases the radiographer was correct, and in four the radiologist was correct. CONCLUSION Experienced radiographers and radiologists are highly accurate in performing and interpreting routine abdominal sonography. Both operators missed a small minority of abnormalities. There was no statistically significant difference in the accuracy of radiographers and radiologist.
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Polyarthritis. IMAGING 1999. [DOI: 10.1259/img.11.2.110098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
Neurofibromatosis Type 1 (NF1) is not classically associated with gastrointestinal manifestations although these patients are at increased risk of several GI complications. We describe the ultrasound, CT and barium findings in a patient with NF1 who had a huge benign plexiform neurofibroma of the ileum that was infiltrated with metastatic adenocarcinoma.
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Staging of squamous cell carcinoma of the oral cavity and oropharynx: a comparison of MRI and CT in T- and N-staging. J Comput Assist Tomogr 1999; 23:43-9. [PMID: 10050806 DOI: 10.1097/00004728-199901000-00010] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Our purpose was to assess the accuracy of CT and MRI in staging of squamous cell carcinoma (SCC) of the oral cavity and oropharynx. METHOD Fifty-one episodes of primary and recurrent SCC were assessed with CT and MRI. The results were compared with pathological staging. RESULTS For staging primary tumours, the accuracy of MR was 77% and that of CT was 67%. For detecting recurrent tumour, the accuracy of MR was 89% and that of CT was 100%. For N-staging, nodal sites were divided, according to the site of the primary tumour, into high and low risk. Sensitivity for high risk sites was 60% for clinical assessment, 35% for CT, and 75% for MR. Negative predictive value (NPV) was < or = 50% for all methods. For low risk sites, the NPV was > or = 95% for all methods. CONCLUSION For T-staging, MR scanning is overall more accurate than CT. If degraded images and T1 tumours are excluded, the techniques are comparable. MR scanning is oversensitive for recurrent disease. For N-staging, all methods failed to detect small metastatic deposits.
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Abstract
OBJECTIVES To determine if there are specific patterns of illness behaviour in patients with arthritis, and if abnormal patterns of illness behaviour are associated with withdrawal from trials of anti-inflammatory drugs, and to examine which aspects of illness behaviour are perceived by rheumatologist to be related to the disease process. METHODS The illness behaviour questionnaire (IBQ) was administered to 211 patients with rheumatoid arthritis (RA) and 107 patients with osteoarthritis (OA) participating in five drug trials of NSAIDs at the beginning of the studies, and was commented upon by 17 clinical rheumatologists. RESULTS Factor analysis of 211 patients with RA produced a unique factor solution. RA patients were more preoccupied with their illness and its effects and worried more about their health than patients with OA. Patients who withdrew from drug trials showed behaviour patterns similar to those of chronic pain patients, and different from those of patients who completed the studies. When asked to account for a rheumatoid patient's response to the IBQ, rheumatologists focused on physical symptoms and did not recognise some of the psychological issues which patients saw as being relevant. CONCLUSIONS We have demonstrated differences in illness behaviour between patients with OA and with RA. Patients withdrawing from drug trials of NSAIDs showed differences in illness behaviour compared with those successfully completing the trials. Rheumatologists underestimated the impact of the disease on their RA patients' psychological well being.
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Reduction of the concentration and total amount of keratan sulphate in synovial fluid from patients with osteoarthritis during treatment with piroxicam. Ann Rheum Dis 1992; 51:850-4. [PMID: 1632658 PMCID: PMC1004767 DOI: 10.1136/ard.51.7.850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To study the effects of piroxicam on cartilage metabolism in vivo, a three phase (placebo/piroxicam 20 mg/day by mouth/placebo) double blind controlled trial was conducted in patients with osteoarthritis of the knee joint. Twenty one patients were recruited, 19 of whom (11 women, eight men, median age 70 years) completed the treatment schedule. The knee joint under study was aspirated to dryness at four week intervals. Treatment with piroxicam was accompanied by a decrease in the pain score, an improvement in the functional index, and an increased range of movement. Reductions in the concentration (mean (SEM) 120 (6) to 110 (8) micrograms/ml) and the total amount (1.22 (0.34) to 0.99 (0.37) mg) of keratan sulphate, but not the effusion volume (9.4 (2.5) to 8.3 (2.6) ml) were observed during treatment with piroxicam. These findings are consistent with decreased proteoglycan catabolism during treatment with piroxicam. Neither depressed synthesis nor enhanced clearance of degraded proteoglycan fragments can be excluded, however.
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Casing the joint. THE HEALTH SERVICE JOURNAL 1992; 102:suppl 6, 9. [PMID: 10118080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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The bioavailability of erythromycin stearate versus enteric-coated erythromycin base when taken immediately before and after food. J Int Med Res 1981; 9:470-7. [PMID: 7319133 DOI: 10.1177/030006058100900608] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
1. Erythromycin plasma concentrations were determined in twenty subjects after a single dose, immediately before food, of erythromycin, 500 mg. as: (1) erythromycin stearate (Erythrocin, 500 mg, ovaloid tablets), and (2) erythromycin base (Eryc, 250 mg, capsules containing enteric-coated pellets). 2. Plasma concentrations were again determined in eighteen of the original subjects with the same dose given immediately after food. 3. Maximum Plasma Concentrations (mcg/ml) (See formula in text) 4. Erythromycin stearate was more bioavailable than erythromycin base when administered immediately before food. The preparations were bioequivalent when given immediately after food.
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Health and medical care in China. THE AUSTRALIAN NURSES' JOURNAL. ROYAL AUSTRALIAN NURSING FEDERATION 1978; 8:50-3. [PMID: 250423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Diet, Growth, Production and Senecence in Relation to Certain Diseases of Sheep. Aust Vet J 1936. [DOI: 10.1111/j.1751-0813.1936.tb01122.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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