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Jenkins V, Matthews L, Solis-Trapala I, Gage H, May S, Williams P, Bloomfield D, Zammit C, Elwell-Sutton D, Betal D, Finlay J, Nicholson K, Kothari M, Santos R, Stewart E, Bell S, McKinna F, Teoh M. Patients' experiences of a suppoRted self-manAGeMent pAThway In breast Cancer (PRAGMATIC): quality of life and service use results. Support Care Cancer 2023; 31:570. [PMID: 37698629 PMCID: PMC10497681 DOI: 10.1007/s00520-023-08002-z] [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: 02/27/2023] [Accepted: 08/16/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE To describe trends and explore factors associated with quality of life (QoL) and psychological morbidity and assess breast cancer (BC) health service use over a 12-month period for patients joining the supported self-management (SSM)/patient-initiated follow-up (PIFU) pathway. METHODS Participants completed questionnaires at baseline, 3, 6, 9 and 12 months that measured QoL (FACT-B, EQ 5D-5L), self-efficacy (GSE), psychological morbidity (GHQ-12), roles and responsibilities (PRRS) and service use (cost diary). RESULTS 99/110 patients completed all timepoints; 32% (35/110) had received chemotherapy. The chemotherapy group had poorer QoL; FACT-B total score mean differences were 8.53 (95% CI: 3.42 to 13.64), 5.38 (95% CI: 0.17 to 10.58) and 8.00 (95% CI: 2.76 to 13.24) at 6, 9 and 12 months, respectively. The odds of psychological morbidity (GHQ12 >4) were 5.5-fold greater for those treated with chemotherapy. Financial and caring burdens (PRRS) were worse for this group (mean difference in change at 9 months 3.25 (95% CI: 0.42 to 6.07)). GSE and GHQ-12 scores impacted FACT-B total scores, indicating QoL decline for those with high baseline psychological morbidity. Chemotherapy patients or those with high psychological morbidity or were unable to carry out normal activities had the highest service costs. Over the 12 months, 68.2% participants phoned/emailed breast care nurses, and 53.3% visited a hospital breast clinician. CONCLUSION The data suggest that chemotherapy patients and/or those with heightened psychological morbidity might benefit from closer monitoring and/or supportive interventions whilst on the SSM/PIFU pathway. Reduced access due to COVID-19 could have affected service use.
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Affiliation(s)
- V Jenkins
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, East Sussex, England, UK.
| | - L Matthews
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, East Sussex, England, UK
| | - I Solis-Trapala
- School of Medicine, Keele University, University Road, Staffordshire, England, UK
| | - H Gage
- Surrey Health Economics Centre/Department of Clinical and Experimental Medicine, Leggett Building, University of Surrey, Guildford, Surrey, England, UK
| | - S May
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, East Sussex, England, UK
| | - P Williams
- Department of Mathematics, University of Surrey, Guildford, Surrey, England, UK
| | - D Bloomfield
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, East Sussex, England, UK
- Surrey & Sussex Cancer Alliance, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, England, UK
| | - C Zammit
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, East Sussex, England, UK
- Surrey & Sussex Cancer Alliance, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, England, UK
| | - D Elwell-Sutton
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, East Sussex, England, UK
| | - D Betal
- Worthing Hospital, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, England, UK
| | - J Finlay
- Worthing Hospital, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, England, UK
| | - K Nicholson
- Worthing Hospital, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, England, UK
| | - M Kothari
- Ashford & St Peter's NHS Foundation Trust, London Road, Ashford, Surrey, England, UK
| | - R Santos
- Ashford & St Peter's NHS Foundation Trust, London Road, Ashford, Surrey, England, UK
| | - E Stewart
- Ashford & St Peter's NHS Foundation Trust, London Road, Ashford, Surrey, England, UK
| | - S Bell
- Surrey & Sussex Cancer Alliance, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, England, UK
| | - F McKinna
- Surrey & Sussex Cancer Alliance, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, England, UK
| | - M Teoh
- Surrey & Sussex Cancer Alliance, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, England, UK
- Ashford & St Peter's NHS Foundation Trust, London Road, Ashford, Surrey, England, UK
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Sarigul B, Bell RS, Chesnut R, Aguilera S, Buki A, Citerio G, Cooper DJ, Diaz-Arrastia R, Diringer M, Figaji A, Gao G, Geocadin RG, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer SA, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo DO, Patel MB, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein DD, Stocchetti N, Taccone FS, Timmons SD, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, Hawryluk GWJ. Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group. J Neurotrauma 2023; 40:1707-1717. [PMID: 36932737 DOI: 10.1089/neu.2022.0414] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 03/19/2023] Open
Abstract
Abstract Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.
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Affiliation(s)
| | - Randy S Bell
- Uniformed Services University of Health Sciences, Avera Brain and Spine Institute, Sioux Falls, South Dakota, USA
| | - Randall Chesnut
- Departments of Neurological Surgery and Orthopaedic Surgery, School of Global Health, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | | | - Andras Buki
- Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- NeuroIntensive Care, Department of Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - D Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Michael Diringer
- Department of Neurology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Anthony Figaji
- Department of Neurosurgery, Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Guoyi Gao
- Division of Neurotrauma, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Romergryko G Geocadin
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Alan Hoffer
- University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Geoffrey Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco General Hospital & Trauma Center, San Francisco, California, USA
| | - Stephan A Mayer
- Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Daniel B Michael
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Beaumont Health, Michigan Head & Spine Institute, Southfield, Michigan, USA
| | - Mauro Oddo
- Directorate of Innovation and Clinical Research, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - David O Okonkwo
- Departments of Neurological Surgery, Neurology and Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center; Center for Health Services Research; Tennessee Valley Healthcare System, Veterans Affairs Medical Center; Section of Surgical Sciences, Department of Surgery, Division of Acute Care Surgery Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Juan Sahuquillo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Spain
| | - Franco Servadei
- Department of Neurosurgery, IRCCS Humanitas Research Hospital and Humanitas University, Milano, Italy
| | - Lori Shutter
- Critical Care Medicine, Neurology and Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah D Stein
- Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Dipartimento Fisiopatologia e Trapianti Universita di Milano, Scuola di Specializzazione Anestesia, Rianimazione, Terapia Intensiva e del Dolore, Neurorianimazione, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Shelly D Timmons
- Department of Neurological Surgery, Indiana University School of Medicine, Indiana, USA
| | - Eve Tsai
- Division of Neurosurgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jamie S Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Paul Vespa
- Department of Neurosurgery and Neurology, UCLA School of Medicine, Neurocritical Care, Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, California, USA
| | - Walter Videtta
- Intensive Care Medicine, Posadas Hospital, Buenos Aires, Argentina
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher Zammit
- Department of Emergency Medicine, University of Rochester Medical Center, School of Medicine and Dentistry, Rochester, New York, USA
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Chesnut RM, Aguilera S, Buki A, Bulger EM, Citerio G, Cooper DJ, Arrastia RD, Diringer M, Figaji A, Gao G, Geocadin RG, Ghajar J, Harris O, Hawryluk GWJ, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer S, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo DO, Patel MB, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein DM, Stocchetti N, Taccone FS, Timmons SD, Tsai EC, Ullman JS, Videtta W, Wright DW, Zammit C. Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations. Neurosurgery 2023; 93:399-408. [PMID: 37171175 PMCID: PMC10319366 DOI: 10.1227/neu.0000000000002516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/02/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. OBJECTIVE To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. METHODS We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. RESULTS Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. CONCLUSION Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.
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Affiliation(s)
- Randall M. Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, USA
- School of Global Health, University of Washington, Seattle, Washington, USA
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Sergio Aguilera
- Almirante Nef Naval Hospital, Valparaiso University, Viña Del Mar, Chile
- Valparaiso University, Valparaiso, Chile
| | - Andras Buki
- Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Eileen M. Bulger
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Neuroscience Department, NeuroIntensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Monza, Italy
| | - D. Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Ramon Diaz Arrastia
- Department of Neurology, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael Diringer
- Department of Neurology, Washington University School of Medicine, St Louis, USA
- Department of Neurology, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, Groote Schuur Hospital, University of Cape Town, Observatory 7925, South Africa
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Romergryko G. Geocadin
- Departments of Neurology, Neurological Surgery, Anesthesiology-Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | - Odette Harris
- Department of Neurosurgery, Stanford University School of Medicine, Center for Academic Medicine, Stanford, California, USA
| | - Gregory W. J. Hawryluk
- Cleveland Clinic Akron General Neurosciences Center, Fairlawn, Ohio, USA
- Uniformed Services University, Bethesda, Maryland, USA
- Brain Trauma Foundation, New York City, New York, USA
| | - Alan Hoffer
- UH Cleveland Medical Center, Cleveland, Ohio, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge and Cambridge Biomedical Campus, Cambridge, UK
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of Neurosurgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Stephan Mayer
- Westchester Health Network, New York Medical College, Valhalla, New York, USA
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Daniel B. Michael
- Department of Neurosurgery, Beaumont Health, Michigan Head and Spine Institute, Oakland University William Beaumont School of Medicine, Southfield, Michigan, USA
| | - Mauro Oddo
- CHUV Medical Directorate and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Mayur B. Patel
- Department of Surgery, Division of Acute Care Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA
| | - Jeffrey V. Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Andres M. Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Juain Sahuquillo
- Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona: Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Milano, Italy
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Deborah M. Stein
- University of Maryland School of Medicine, Adult Critical Care Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Shelly D. Timmons
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eve C. Tsai
- Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, The Ottawa Hospital, Department of Surgery, Division of Neurosurgery, University of Ottawa, Civic Campus, Ottawa, Ontario, Canada
| | - Jamie S. Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Walter Videtta
- Intensive Care, Posadas Hospital, Buenos Aires, Argentina
| | - David W. Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher Zammit
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
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Matthews L, Teoh M, May S, Zammit C, Bloomfield D, Kothari M, Betal D, Santos R, Stewart E, Finlay J, Nicholson K, Elwell-Sutton D, McKinna F, Gage H, Bell S, Jenkins V. CN61 Patients’ experiences of a suppoRted self-manAGeMent pAThway In breast Cancer (PRAGMATIC): Interview results. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Farrugia Y, Spiteri Meilak BP, Grech N, Asciak R, Camilleri L, Montefort S, Zammit C. The Impact of COVID-19 on Hospitalised COPD Exacerbations in Malta. Pulm Med 2021; 2021:5533123. [PMID: 34258061 PMCID: PMC8241528 DOI: 10.1155/2021/5533123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/03/2021] [Accepted: 06/12/2021] [Indexed: 11/26/2022] Open
Abstract
METHOD Data was collected retrospectively from electronic hospital records during the periods 1st March until 10th May in 2019 and 2020. RESULTS There was a marked decrease in AECOPD admissions in 2020, with a 54.2% drop in admissions (n = 119 in 2020 vs. n = 259 in 2019). There was no significant difference in patient demographics or medical comorbidities. In 2020, there was a significantly lower number of patients with AECOPD who received nebulised medications during admission (60.4% in 2020 vs. 84.9% in 2019; p ≤ 0.001). There were also significantly lower numbers of AECOPD patients admitted in 2020 who received controlled oxygen via venturi masks (69.0% in 2020 vs. 84.5% in 2019; p = 0.006). There was a significant increase in inpatient mortality in 2020 (19.3% [n = 23] and 8.4% [n = 22] for 2020 and 2019, respectively, p = 0.003). Year was found to be the best predictor of mortality outcome (p = 0.001). The lack of use of SABA pre-admission treatment (p = 0.002), active malignancy (p = 0.003), and increased length of hospital stay (p = 0.046) were also found to be predictors of mortality for AECOPD patients; however, these parameters were unchanged between 2019 and 2020 and therefore could not account for the increase in mortality. CONCLUSIONS There was a decrease in the number of admissions with AECOPD in 2020 during the COVID-19 pandemic, when compared to 2019. The year 2020 proved to be a significant predictor for inpatient mortality, with a significant increase in mortality in 2020. The decrease in nebuliser and controlled oxygen treatment noted in the study period did not prove to be a significant predictor of mortality when corrected for other variables. Therefore, the difference in mortality cannot be explained with certainty in this retrospective cohort study.
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Affiliation(s)
- Yvette Farrugia
- Mater Dei Hospital, Triq id-Donaturi tad-Demm, Msida MSD2090, Malta
| | | | - Neil Grech
- Mater Dei Hospital, Triq id-Donaturi tad-Demm, Msida MSD2090, Malta
| | - Rachelle Asciak
- Mater Dei Hospital, Triq id-Donaturi tad-Demm, Msida MSD2090, Malta
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Roh D, Torres GL, Cai C, Zammit C, Reynolds AS, Mitchell A, Connolly ES, Claassen J, Grotta JC, Choi HA, Chang TR. Coagulation Differences Detectable in Deep and Lobar Primary Intracerebral Hemorrhage Using Thromboelastography. Neurosurgery 2021; 87:918-924. [PMID: 32167143 DOI: 10.1093/neuros/nyaa056] [Citation(s) in RCA: 6] [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: 08/15/2019] [Accepted: 01/29/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There are radiographic and clinical outcome differences between patients with deep and lobar intracerebral hemorrhage (ICH) locations. Pilot studies suggest that there may be functional coagulation differences between these locations detectable using whole blood coagulation testing. OBJECTIVE To confirm the presence of interlocation functional coagulation differences using a larger cohort of deep and lobar ICH patients receiving whole blood coagulation testing: thromboelastography (TEG; Haemonetics). METHODS Clinical and laboratory data were prospectively collected between 2009 and 2018 for primary ICH patients admitted to a tertiary referral medical center. Deep and lobar ICH patients receiving admission TEG were analyzed. Patients with preceding anticoagulant use and/or admission coagulopathy (using prothrombin time/partial thromboplastin time/platelet count) were excluded. Linear regression models assessed the association of ICH location (independent variable) with TEG and traditional plasma coagulation test results (dependent variable) after adjusting for baseline hematoma size, age, sex, and stroke severity. RESULTS We identified 154 deep and 53 lobar ICH patients who received TEG. Deep ICH patients were younger and had smaller admission hematoma volumes (median: 16 vs 29 mL). Adjusted multivariable linear regression analysis revealed longer TEG R times (0.57 min; 95% CI: 0.02-1.11; P = .04), indicating longer clot formation times, in deep compared to lobar ICH. No other TEG parameter or plasma-based coagulation differences were seen. CONCLUSION We identified longer clot formation times, suggesting relative coagulopathy in deep compared to lobar ICH confirming results from prior work. Further work is required to elucidate mechanisms for these differences and whether ICH location should be considered in future coagulopathy treatment paradigms for ICH.
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Affiliation(s)
- David Roh
- Department of Neurology, Columbia University, New York, New York
| | - Glenda L Torres
- Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Chunyan Cai
- Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, Texas
| | - Christopher Zammit
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | | | - Amanda Mitchell
- Department of Neurology, Columbia University, New York, New York
| | | | - Jan Claassen
- Department of Neurology, Columbia University, New York, New York
| | - James C Grotta
- Department of Neurology, Memorial Hermann Hospital Texas Medical Center, Houston, Texas
| | - Huimahn A Choi
- Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Tiffany R Chang
- Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas
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7
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Roh D, Chang T, Zammit C, Wagener G, Reynolds AS, Yoh N, Elkind MSV, Doyle K, Boehme A, Eisenberger A, Francis RO, Park S, Agarwal S, Connolly ES, Claassen J, Hod E. Functional Coagulation Differences Between Lobar and Deep Intracerebral Hemorrhage Detected by Rotational Thromboelastometry: A Pilot Study. Neurocrit Care 2020; 31:81-87. [PMID: 30693412 DOI: 10.1007/s12028-019-00672-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 10/27/2022]
Abstract
BACKGROUND Lobar intracerebral hemorrhage (ICH) is known to have better clinical outcomes and preliminary evidence of less hematoma expansion compared to deep ICH. No functional coagulation differences between lobar and deep ICH have been identified using traditional plasma-based coagulation tests. We investigated for coagulation differences between lobar and deep ICH using whole-blood coagulation testing (Rotational Thromboelastometry: [ROTEM]). METHODS Clinical, radiographic, and laboratory data were prospectively collected for primary ICH patients enrolled in a single-center ICH study. Patients with preceding anticoagulant use or admission coagulopathy on traditional laboratory testing were excluded. Lobar and deep ICH patients receiving admission ROTEM were analyzed. Linear regression was used to assess the association of ICH location with coagulation test results after adjusting for potential confounders. RESULTS There were 12 lobar and 19 deep ICH patients meeting inclusion criteria. Lobar ICH patients were significantly older and predominantly female. Lobar ICH had faster intrinsic pathway coagulation times (139.8 vs 203.2 s; 95% CI - 179.91 to - 45.96; p = 0.002) on ROTEM testing compared to deep ICH after adjusting for age, sex, and hematoma volume. This revealed functional coagulation differences, specifically quicker clot formation in lobar compared to deep ICH. No differences were noted using traditional coagulation testing (prothrombin time/partial thromboplastin time/platelet count). CONCLUSIONS Our pilot data may suggest that there are functional coagulation differences between lobar and deep ICH identified using ROTEM. Whole-blood coagulation testing may be useful in assessing coagulopathy in ICH patients and in determining reversal treatment paradigms, though further work is needed.
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Affiliation(s)
- David Roh
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA.
| | - Tiffany Chang
- University of Texas Houston Medical Center, Houston, TX, USA
| | | | - Gebhard Wagener
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Alexandra S Reynolds
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Nina Yoh
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Mitchell S V Elkind
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Kevin Doyle
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Amelia Boehme
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Andrew Eisenberger
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Richard O Francis
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Soojin Park
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Sachin Agarwal
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - E Sander Connolly
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Jan Claassen
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Eldad Hod
- Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
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8
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Zammit C, Gallagher S, Burgett J, Grassman C, L'Esperance J, Pilcher W, Benesch C, Bhalla T. Abstract TP265: Far-Forward Stroke Care: Parallel Processing in the Prehospital Environment May Achieve Door-to-Needle Times of Less Than 15 Minutes on a Mobile Stroke Treatment Unit. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tp265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The time from 911 activation (i.e. alarm) to administration of intravenous (IV) alteplase in acute ischemic stroke is associated with functional, patient centered-outcomes. Mobile stroke treatment units (MSTUs) have emerged as a stroke system tool that may hasten treatment times. Optimal workflows on MSTUs remain to fully elucidated.
Methods:
Retrospective review of a QA database of patients treated on a MSTU with door-to-needle-times (DTN) of </= 15 minutes to describe workflows and team dynamics that were associated with expeditious treatment.
Results:
In October of 2018 the University of Rochester Medical Center launched a MSTU, initially operating on Monday through Friday in the city of Rochester from 8am until 4 pm. Over the initial 3 months, there were 96 MSTU responses leading to 54 transported patients, 3 of which were treated with IV alteplase. One patient with an initial NIHSS of 17 was treated with IV alteplase within 9 minutes of reaching the MSTU door. Workflow elements felt to hasten treatment included registration of the patient in the electronic health record (EHR) prior to the patient reaching the MSTU and enabling the telestroke provider to listen to the initial history and physical being performed by the MSTU RN at the scene. The later is accomplished by using a telestroke iPhone application that allows for a “3-way-call” between the MSTU RN, the MSTU, and the telestroke provider. The MSTU RN wears a Bluetooth earpiece that captures the conversation with the patient, witnesses on scene, and initial EMS responders and enables the MSTU RN to summarizes key history and exam findings, vitals, and blood glucose results while keeping their hands available for patient care. Simultaneously, the telestroke provider reviews the patient’s chart in the EHR for alteplase contraindications, prior imaging results, and pertinent medical history.
Conclusion:
Registering the patient in the EHR and integrating the telestroke provider into the initial patient assessment at the scene in the prehospital setting may allow for consistent door to needle times of < 15 minutes on MSTUs, which may further improve patient outcomes.
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9
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Zammit C, Gallagher S, Proper D, George B, Halpert D, Emmons J, Talbott M, Lux J, Teeter MA, Bose-Kolanu A, Holloway R, Pilcher W, Benesch C, Mattingly T, Bhalla T. Abstract TMP72: Auto-Launching of Interfacility Transport for Presumed Emergent Large Vessel Occlusion Strokes Decreases Door-In-Door-Out (DIDO) Times and May Improve Outcomes. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tmp72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Mechanical thrombectomy (MT) is effective for select acute ischemic strokes due to large vessel occlusion (LVO-AIS). Systems of care need to expeditiously identify, transfer, and treat qualifying LVO-AIS. Data are needed to define which ingredients are most effective when engineering LVO-AIS regional systems of care.
Methods:
Strong Memorial Hospital (SMH) is a Comprehensive Stroke Center in Rochester, NY serving twenty-two New York State designed stroke centers (NYS-DSC). Arnot Ogden Medical Center (AOMC), Cayuga Medical Center (CMC), and Geneva General Hospital (GGH) are NYS-DSCs located 115, 91, and 50 miles from SMH, respectively. Clinical leaders at each site collaborated to implement an integrated regional system of care for LVO-AIS, dubbed “Code LVO”, which includes the auto-launching of an interfacility transport to the referring hospital for presumed strokes with an NIHSS of >/= 10 and last known well time (LKWT) of </=24 hours. We retrospectively reviewed a QA database for transfer patients with an ASPECTS of >/= 6 and proximal anterior circulation LVO on a CTA at the referring hospital to identify the door-in-door-out (DIDO) times, thrombectomy attempt rate, and mortality of patients before and after Code LVO implementation. Wilcoxon Rank-Sum was used to analyze median DIDO times and Fisher’s exact was used to analyze the proportion of DIDO times of < 90 minutes, < 60 minutes, thrombectomy attempt rate, and mortality.
Results:
There were 51 pre- Code LVO versus 12 post Code-LVO transfers. The median DIDO times were significantly reduced post-Code LVO (80 vs 127 minutes, p=0.001). The proportion of DIDO times < 90 minutes and < 60 minutes were significantly improved (58% vs 16%, p=0.005 and 17% vs 0%, p=0.034, respectively). Mortality was numerically, but not significantly, reduced (17% vs 22%). Median DIDO times were significantly shorter in those undergoing thrombectomy (97 vs 136 minutes, p=0.008) and numerically longer in those who died (138 vs 112 minutes, p=0.24).
Conclusions:
Auto-launching of interfacility transport within an integrated regional system care for LVO-AIS decreases DIDO times and may improve outcomes. Further study is needed to outline its value, in terms of patient outcomes, resource utilization, and safety.
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10
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Chesnut R, Aguilera S, Buki A, Bulger E, Citerio G, Cooper DJ, Arrastia RD, Diringer M, Figaji A, Gao G, Geocadin R, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer S, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo D, Patel M, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein D, Stocchetti N, Taccone FS, Timmons S, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, Hawryluk GWJ. A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med 2020; 46:919-929. [PMID: 31965267 PMCID: PMC7210240 DOI: 10.1007/s00134-019-05900-x] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 12/14/2019] [Indexed: 12/20/2022]
Abstract
Background Current guidelines for the treatment of adult severe traumatic brain injury (sTBI) consist of high-quality evidence reports, but they are no longer accompanied by management protocols, as these require expert opinion to bridge the gap between published evidence and patient care. We aimed to establish a modern sTBI protocol for adult patients with both intracranial pressure (ICP) and brain oxygen monitors in place. Methods Our consensus working group consisted of 42 experienced and actively practicing sTBI opinion leaders from six continents. Having previously established a protocol for the treatment of patients with ICP monitoring alone, we addressed patients who have a brain oxygen monitor in addition to an ICP monitor. The management protocols were developed through a Delphi-method-based consensus approach and were finalized at an in-person meeting. Results We established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. The panel considered issues pertaining to blood transfusion and ventilator management when designing the different algorithms. Conclusions These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management. These protocols should be used in conjunction with recommendations for basic care, management of critical neuroworsening and weaning treatment recently published in conjunction with the Seattle International Brain Injury Consensus Conference. Electronic supplementary material The online version of this article (10.1007/s00134-019-05900-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Randall Chesnut
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, Washington, 98104-2499, USA.,Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, Washington, 98104-2499, USA
| | - Sergio Aguilera
- Almirante Nef Naval Hospital, Viña del Mar, Chile.,Valparaiso University, Valparaiso, Chile
| | - Andras Buki
- Department of Neurosurgery, Medical School and Szentágothai Research Centre, Ifjúság útja 20, 7624, Pécs, Hungary.,University of Pécs, Pécs, Hungary
| | - Eileen Bulger
- Department of Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Seattle, WA, 98104-2499, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy
| | - D Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Monash, Australia.,Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
| | - Ramon Diaz Arrastia
- University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, 51 North 39th Street, Philadelphia, PA, 19104, USA
| | - Michael Diringer
- Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, 1 Barnes-Jewish Hospital Plaza, St. Louis, MO, 63110, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, Main Road, Observatory, 7925, South Africa
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, Shanghai Jiaotong University School of Medicine, 1630 Dongfang Road, Shanghai, 200127, China
| | - Romer Geocadin
- Johns Hopkins University School of Medicine, 1800 Orleans St. Sheikh Zayed Tower, Baltimore, MD, 21287, USA
| | - Jamshid Ghajar
- Stanford Neuroscience Health Center, 213 Quarry Rd 4th Fl MC 5958, Palo Alto, CA, 94304, USA
| | - Odette Harris
- Department of Neurosurgery, Pasteur Drive, Room R205, Edward's Building, MC 5327, Stanford, CA, 94305, USA
| | - Alan Hoffer
- Department of Neurological Surgery, School of Medicine, Case Western Reserve University, 11100 Euclid Avenue, HAN 5042, Cleveland, OH, 44106, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, 6400 Fannin St, Suite 2800, Houston, TX, 77030, USA
| | - Geoffrey Manley
- University of California San Francisco, San Francisco General Hospital and Trauma Center, 1001 Potrero Ave., Bldg 1, Room 101, San Francisco, CA, 94110, USA
| | - Stephan Mayer
- Neurology, K-11, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, Addenbrooke's Hospital, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Herestraat 49, Box 7003 63, 3000, Leuven, Belgium
| | - Daniel B Michael
- Oakland University William Beaumont School of Medicine, Beaumont Health, Michigan Head and Spine Institute, Southfield, MI, USA
| | - Mauro Oddo
- Department of Intensive Care Medicine, CHUV-Lausanne University Hospital, University of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland
| | - David Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mayur Patel
- Vanderbilt University Medical Center, Nashville, USA
| | - Claudia Robertson
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Calle 7-A # 44-95, 760036, Cali, Colombia
| | | | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy.,World Federation of Neurosurgical Societies, Nyon, Switzerland
| | - Lori Shutter
- University of Pittsburgh Medical Center, 3550 Terrace St, Room 646, Pittsburgh, PA, 15261, USA
| | - Deborah Stein
- Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, 1001 Potrero Ave., Ward 3A, San Francisco, CA, 94110, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy.,Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Shelly Timmons
- Department of Neurological Surgery, Penn State University Milton S. Hershey Medical Center, 30 Hope Dr., Suite 1200
- Building B, Hershey, PA, 17033, USA
| | - Eve Tsai
- Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, University of Ottawa, The Ottawa Hospital, C2 Neurosciences Unit, The Ottawa Hosptial, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Jamie S Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine At Hofstra/Northwell North, Shore University Hospital, 300 Community Drive, 9 Tower, Manhasset, NY, USA
| | - Paul Vespa
- Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, Santa Monica, USA
| | | | - David W Wright
- Emory University School of Medicine, 49 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA
| | - Christopher Zammit
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 655C, Rochester, NY, 14642, USA
| | - Gregory W J Hawryluk
- Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
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11
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Conti L, Gatt K, Zammit C, Cassar K. Kounis syndrome uncovers severe coronary disease: an unusual case of acute coronary syndrome secondary to allergic coronary vasospasm. BMJ Case Rep 2019; 12:12/12/e232472. [DOI: 10.1136/bcr-2019-232472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute coronary syndrome occurring during the course of a type I hypersensitivity reaction constitutes Kounis syndrome. We report a case of a 64-year-old man who presented with a non-ST elevation myocardial infarction and peripheral blood eosinophilia. He had rhinitis and constitutional symptoms for several days prior to presentation. Blood investigations revealed moderate eosinophilia and elevated IgE levels. A cardiac MRI showed generalised oedema with a subtle wall motion abnormality in basal inferior/inferolateral wall, and subendocardial high signal on late gadolinium enhancement suggesting a localised myocardial infarction. A coronary angiogram then revealed triple vessel disease. A diagnosis of Kounis syndrome was made. Within days of starting appropriate treatment, the patient’s eosinophil count returned to normal with improvement of clinical picture.
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12
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Hawryluk GWJ, Aguilera S, Buki A, Bulger E, Citerio G, Cooper DJ, Arrastia RD, Diringer M, Figaji A, Gao G, Geocadin R, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer S, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo D, Patel M, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein D, Stocchetti N, Taccone FS, Timmons S, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, Chesnut RM. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med 2019; 45:1783-1794. [PMID: 31659383 PMCID: PMC6863785 DOI: 10.1007/s00134-019-05805-9] [Citation(s) in RCA: 248] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/25/2019] [Indexed: 01/01/2023]
Abstract
Background Management algorithms for adult severe traumatic brain injury (sTBI) were omitted in later editions of the Brain Trauma Foundation’s sTBI Management Guidelines, as they were not evidence-based. Methods We used a Delphi-method-based consensus approach to address management of sTBI patients undergoing intracranial pressure (ICP) monitoring. Forty-two experienced, clinically active sTBI specialists from six continents comprised the panel. Eight surveys iterated queries and comments. An in-person meeting included whole- and small-group discussions and blinded voting. Consensus required 80% agreement. We developed heatmaps based on a traffic-light model where panelists’ decision tendencies were the focus of recommendations. Results We provide comprehensive algorithms for ICP-monitor-based adult sTBI management. Consensus established 18 interventions as fundamental and ten treatments not to be used. We provide a three-tier algorithm for treating elevated ICP. Treatments within a tier are considered empirically equivalent. Higher tiers involve higher risk therapies. Tiers 1, 2, and 3 include 10, 4, and 3 interventions, respectively. We include inter-tier considerations, and recommendations for critical neuroworsening to assist the recognition and treatment of declining patients. Novel elements include guidance for autoregulation-based ICP treatment based on MAP Challenge results, and two heatmaps to guide (1) ICP-monitor removal and (2) consideration of sedation holidays for neurological examination. Conclusions Our modern and comprehensive sTBI-management protocol is designed to assist clinicians managing sTBI patients monitored with ICP-monitors alone. Consensus-based (class III evidence), it provides management recommendations based on combined expert opinion. It reflects neither a standard-of-care nor a substitute for thoughtful individualized management. Electronic supplementary material The online version of this article (10.1007/s00134-019-05805-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gregory W J Hawryluk
- Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
| | - Sergio Aguilera
- Almirante Nef Naval Hospital, Valparaiso University, Viña Del Mar, Chile.,Valparaiso University, Valparaiso, Chile
| | - Andras Buki
- Department of Neurosurgery, Medical School and Szentágothai Research Centre, Ifjúság Útja 20, Pécs, 7624, Hungary.,University of Pécs, Pécs, Hungary
| | - Eileen Bulger
- Department of Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Seattle, WA, 98104-2499, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Anaesthesia and Intensive Care, San Gerardo and Desio Hospitals, ASST-Monza, Monza, Italy
| | - D Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Ramon Diaz Arrastia
- Department of Neurology, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, 51 North 39th Street, Philadelphia, PA, 19104, USA
| | - Michael Diringer
- Department of Neurology, Washington University School of Medicine, St. Louis, USA.,Department of Neurology, Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza Suite 10400, St. Louis, MO, 63110, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, Groote Schuur Hospital¸University of Cape Town, H53 Old Main Building, Main Road, Observatory, 7925, South Africa
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, Shanghai Jiaotong University School of Medicine, 1630 Dongfang Road, Shanghai, 200127, China
| | - Romergryko Geocadin
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford Neuroscience Health Center, 213 Quarry Rd 4th Fl, MC 5958, Palo Alto, CA, 94304, USA
| | - Odette Harris
- Department of Neurosurgery, 300 Pasteur Drive, Room R205, Edward's Building, MC: 5327, Stanford, CA, 94305, USA
| | - Alan Hoffer
- Department of Neurological Surgery, School of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 5042, Cleveland, OH, 44106, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge and Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, 6400 Fannin St, Suite 2800, Houston, TX, 77030, USA
| | - Geoffrey Manley
- Department of Neurosurgery, San Francisco General Hospital and Trauma Center, University of California San Francisco, 1001 Potrero Ave., Bldg 1, Room 101, San Francisco, CA, 94110, USA
| | - Stephan Mayer
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Neurology, K-11, Detroit, MI, 48202, USA
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge and Addenbrooke's Hospital, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Herestraat 49, Box 7003 63, 3000, Leuven, Belgium
| | - Daniel B Michael
- Department of Neurosurgery, Beaumont Health, Michigan Head and Spine Institute, Oakland University William Beaumont School of Medicine, Southfield, MI, USA
| | - Mauro Oddo
- Department of Intensive Care Medicine, Faculty of Biology and Medicine, CHUV-Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - David Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center Presbyterian, Suite B-400 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Mayur Patel
- Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 MAB, Nashville, TN, 37212, USA
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Calle 7-A # 44-95, Cali, 760036, Colombia
| | - Juan Sahuquillo
- Department of Neurosurgery, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh Medical Center, 3550 Terrace St, Room 646, Pittsburgh, PA, 15261, USA
| | - Deborah Stein
- Department of Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Ave., Ward 3A, San Francisco, CA, 94110, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy.,Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Shelly Timmons
- Department of Neurological Surgery, GH 5100 SNEU, Indianapolis, IN, 46202, USA
| | - Eve Tsai
- Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, The Ottawa Hospital, Department of Surgery, Division of Neurosurgery, University of Ottawa, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Jamie S Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, 9 Tower, Manhasset, NY, USA
| | - Paul Vespa
- Gary L. Brinderson Family Chair in Neurocritical Care, UCLA School of Medicine, Los Angeles, USA.,Critical Care Medicine Research, UCLA School of Medicine, Santa Monica, USA.,Neurosurgery and Neurology, UCLA School of Medicine, Santa Monica, USA.,Neurocritical Care, Ronald Reagan UCLA Medical Center, Santa Monica, USA
| | - Walter Videtta
- Intensive Care, Posadas Hospital, Buenos Aires, Argentina
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, 49 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA
| | - Christopher Zammit
- Department of Emergency Medicine, University of Rochester Medical Center, 265 Crittenden Blvd, Suite 2100, Box 655C, Rochester, NY, 14642, USA
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Mailstop 359766, 325 Ninth Ave, Seattle, WA, 98104-2499, USA. .,Department of Orthopaedic Surgery, University of Washington, Mailstop 359766, 325 Ninth Ave, Seattle, WA, 98104-2499, USA. .,School of Global Health, University of Washington, Mailstop 359766, 325 Ninth Ave, Seattle, WA, 98104-2499, USA. .,Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, WA, 98104-2499, USA.
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13
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Conti L, Gatt K, Zammit C, Montefort S, Bilocca D. Comparison of aeroallergen sensitisation patterns in the United States and Europe. Ital J Med 2019. [DOI: 10.4081/itjm.2019.1189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The global prevalence of allergic diseases have increased considerably and are a major socio-economic burden. Asthma is a complex disease and understanding asthma phenotypes and endotypes could eventually lead to individualised management, and offer better symptom control and quality of life. In this review, we first summarise the pathogenesis of atopic asthma and delve into the assessment of sensitisation to aeroallergens through skin prick testing and serological testing with total and specific immunoglobulin E testing. We will then analyse the distribution of aeroallergen sensitisation patterns in the United States and Europe and its effect on the population. This review gives a comprehensive overview on atopy and it compares the prevalence and effect of atopy within various regions of both continents using data from large multicentre studies. We will conclude this review by discussing the efficacy of add-on treatments in the most prevalent severe asthma phenotypes and endotypes.
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14
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Conti L, Zammit C. Incidental tracheal bronchus in a case of Hamman-Rich syndrome. BMJ Case Rep 2019; 12:12/5/e229579. [DOI: 10.1136/bcr-2019-229579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Debourdeau P, Simonin C, Carbasse C, Debourdeau T, Zammit C, Scotté F. [Primary prophylaxis of venous thromboembolism in ambulatory cancer patients treated with antineoplastic agents]. Rev Med Interne 2019; 40:523-532. [PMID: 30928244 DOI: 10.1016/j.revmed.2019.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/27/2019] [Accepted: 03/12/2019] [Indexed: 11/29/2022]
Abstract
Apart from myeloma, primary prophylaxis of venous thromboembolism (VTE) in ambulatory cancer patients treated with chemotherapy is underused, despite its proven benefit for pancreatic cancer and to a lesser extent for lung cancer. This prophylaxis has been showed to be effective for myeloma, pancreas but in absolute numbers these cancers lead to a few venous thromboembolic events. Up to date, VTE risk scores cannot be used as a discriminatory criterion to select a high-risk population that could really benefit from this prevention. VTE depends in part on oncogenic mutations of tumor cells that result in an imbalance between activation and inhibition pathways that are involved in venous thrombus formation. So, stratification of risk of VTE in cancer patients could be considered from a clinical and molecular point of view and result in a tailored prophylaxis. This "personalized medicine" that is currently used for the anti-tumor treatment of many cancers and hematological malignancies, could lead to a more effective prophylaxis of VTE in cancer patients.
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Affiliation(s)
- P Debourdeau
- Institut Sainte Catherine, 250, chemin de Baigne-Pieds, CS 80005, 84918 Avignon cedex 09, France.
| | - C Simonin
- Institut Sainte Catherine, 250, chemin de Baigne-Pieds, CS 80005, 84918 Avignon cedex 09, France
| | - C Carbasse
- Institut Sainte Catherine, 250, chemin de Baigne-Pieds, CS 80005, 84918 Avignon cedex 09, France
| | - T Debourdeau
- Faculté de médecine Lyon est, université Claude Bernard Lyon 1, 8, boulevard Rockefeller, 69008 Lyon, France
| | - C Zammit
- Hôpitaux des Portes de Camargue, route d'Arles, 13150 Tarascon, France
| | - F Scotté
- Hôpital Foch, 40, rue Worth, BP 36, 92151 Suresnes cedex, France
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16
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Leonhardt-Caprio AM, Gallagher SA, Chen SR, Zammit C, Risco J. Abstract WP320: Coaching Stroke Quarterbacks in an Academic Medical Center to Improve Door to Treatment Times. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Rapid treatment for acute ischemic stroke (AIS) improves patient outcomes. In an academic medical center AIS treatment often involves a large team including trainees. A clear process allowing for rotating team members and varied experience in AIS care across disciplines is key for timely intervention.
Purpose:
To improve the percentage of patients with door to needle (DTN) and door to puncture (DTP) times within 45 and 90 minutes.
Methods:
A multidisciplinary team including EMS, Emergency Medicine (EM), Nursing, Radiology, Neurology, Neurosurgery, Pharmacy, Surgical Services, and Operations Excellence, along with residents from each specialty, convened for a Lean initiative to reduce door to treatment (DTT) times in an academic Comprehensive Stroke Center. An extensive process map was generated that identified 1) unclear role delineation for EM, Neurology, and Neurosurgery residents, and 2) uncertainty in optimizing the simultaneous processes of history-taking, NIHSS assessment and imaging determination. A model clarifying CT decision–making guidelines and designating a team leader or “Stroke Quarterback” was developed. A three month test of the process was conducted.
Results:
There was a 42% improvement in DTN within 45 minutes and 33.4% improvement in DTP within 90 minutes when compared to the same 3 month period one year prior to the test of change (figure 1). The rate of DTT within goal varied from month to month.
Conclusions:
Despite the varied levels of experience and training of providers at an academic hospital, the acute stroke response team must provide consistent and expeditious care in every instance. Identifying a team leader as a “stroke quarterback” allows for real-time decision-making (audibles), clear delegation of responsibilities (player assignments) based on experience, and utilization of structured processes (playbook). Our model is well-suited for the academic medical center environment and appears to reduce time to treatment.
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17
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Zammit C, Gallagher S, Teeter MA, Lux J, Leonhardt-Caprio AM, Holloway R, Pilcher W, Mattingly T, Bhalla T, Benesch C. Abstract WP286: Auto-launching of Interfacility Transport to Referring Hospitals for Presumed Emergent Large Vessel Occlusion Strokes May Decrease Time to Mechanical Thrombectomy and Improve Outcomes. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Mechanical thrombectomy (MT) is effective for select acute ischemic strokes due to large vessel occlusion (LVO-AIS). Systems of care need to expeditiously identify, transfer, and treat qualifying LVO-AIS. Data are needed to define which ingredients are most effective when engineering LVO-AIS regional systems of care.
Methods:
Strong Memorial Hospital (SMH) is a Comprehensive Stroke Center in Rochester, NY serving twenty-two New York State designed stroke centers (NYS-DSC). Arnot Ogden Medical Center (AOMC) is NYS-DSC located in Elmira, NY, 115 miles from SMH. Clinical leaders at SMH and AOMC collaborated to engineer a system of care to expeditiously transfer qualifying MT candidates. The system of care, dubbed Code LVO, included the auto-launching of an interfacility transport team (preferable a medical helicopter) to AOMC and notification to the SMH Vascular Neurologist (VN) on ED arrival for any presumed strokes with an NIHSS of >/= 10 and last known well time (LKWT) of </=24 hours to review the non-contrast Head CT (NCCT) and CTA of the head and neck for an ASPECTS Score >/=6 and an LVO via a cloud-based image sharing platform. We retrospectively reviewed the records of LVO-AIS transfers in a QA database to identify the door-in-door-out (DIDO) time, AOMC door to SMH door (D2D) time, and AOMC door to SMH skin puncture (D2S) time, and the outcomes of patients before and after Code LVO implementation.
Results:
Over an 18-month period pre- Code LVO, there were seven AOMC to SMH LVO-AIS transfers. None underwent MT due to large or completed infarcts on SMH arrival. Seventy-one percent died or went to hospice. The median DIDO time was 93 minutes (range 66-273) and D2D was 239 minutes (range 112-392). Post- Code LVO, six Code LVO evaluations were requested, and three were transferred. All LVO-AIS underwent successful MT, with a median DIDO time of 45 minutes (range 44-60), D2D time of 95 minutes (range 85-102), and DTS time of 141 minutes (124-158) and went to nursing home or acute rehab.
Conclusions:
Auto-launching of interfacility transport to referring hospitals for select presumed LVO-AIS may decrease time to MT and improve outcomes. Further study is needed to outline its value, in terms of patient outcomes, resource utilization, and safety.
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18
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Roh D, Torres GL, Cai C, Zammit C, Connolly ES, Claassen J, Grotta JC, Choi HA, Chang TR. Abstract TP447: Coagulation Differences Between Deep and Lobar Intracerebral Hemorrhage Detected by Thromboelastography. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Despite smaller baseline hematoma volumes, deep primary intracerebral hemorrhage (ICH) is known to have worse clinical outcomes and preliminary evidence of more hematoma expansion compared to lobar ICH. This is not thought to be related to differences in functional coagulation as prior studies have not identified differences in traditional, plasma-based coagulation tests between these locations. We investigated for clotting differences between deep and lobar ICH using Thromboelastography (TEG: whole-blood coagulation assessment).
Methods:
Clinical, radiographic and laboratory data was prospectively collected between 2009-2018 for primary ICH patients admitted to University of Texas Health Sciences Center at Houston. Deep and lobar ICH patients, without preceding history of anticoagulation use or coagulopathy on admission testing, who received admission TEG and traditional plasma coagulation tests were included for analysis. Patients receiving hemorrhage reversal transfusions prior to TEG were excluded. Multivariable linear regression assessed the association of ICH location with functional coagulation tests after adjusting for age, sex, NIHSS, and baseline hematoma volume.
Results:
Of 207 ICH patients included for analysis, there were 154 (74%) deep and 53 (26%) lobar ICH. Deep ICH patients were significantly younger (mean: 56 vs 68 years), had higher admission systolic blood pressures (mean: 200 vs 182mmHg) and smaller admission hematoma volumes (median: 16.2 vs 28.7mL) than lobar ICH patients. Deep ICH had longer TEG R times (mean: 5.1 vs 4.4 minutes) indicating a slower and less optimal time to clot formation compared to lobar ICH. After controlling for potential confounders, the adjusted mean R times continued to be longer in deep compared to lobar ICH by 0.57 minutes (95% CI 0.02-1.11, p=0.04).
Conclusions:
Our findings suggest that there may be functional coagulation differences detected with whole blood coagulation testing between deep and lobar ICH. Further work is needed to determine whether whole blood coagulation testing to assess coagulopathy after ICH should play a role in hemorrhage reversal treatment paradigms.
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Affiliation(s)
- David Roh
- Columbia Univ Irving Med Cntr, New York, NY
| | | | - Chunyan Cai
- Univ of Texas Health Sciences Cntr at Houston, Houston, TX
| | | | | | | | - James C Grotta
- Univ of Texas Health Sciences Cntr at Houston, Houston, TX
| | - Huimahn A Choi
- Univ of Texas Health Sciences Cntr at Houston, Houston, TX
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19
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Khan I, Rehan M, Parikh G, Zammit C, Badjatia N, Herr D, Kon Z, Hogue C, Mazzeffi M. Regional Cerebral Oximetry as an Indicator of Acute Brain Injury in Adults Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation-A Prospective Pilot Study. Front Neurol 2018; 9:993. [PMID: 30532730 PMCID: PMC6265435 DOI: 10.3389/fneur.2018.00993] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/05/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Regional cerebral oxygen saturation (rScO2) measured by near-infrared spectroscopy (NIRS) can be used to monitor brain oxygenation in extracorporeal membrane oxygenation (ECMO). ECMO patients that develop acute brain injuries (ABIs) are observed to have worse outcomes. We evaluated the association between rScO2 and ABI in venoarterial (VA) ECMO patients. Methods: We retrospectively reviewed prospectively-collected NIRS data from patients undergoing VA ECMO from April 2016 to October 2016. Baseline demographics, ECMO and clinical characteristics, cerebral oximetry data, neuroradiographic images, and functional outcomes were reviewed for each patient. rScO2 desaturations were defined as a >25% decline from baseline or an absolute value < 40% and quantified by frequency, duration, and area under the curve per hour of NIRS monitoring (AUC rate, rScO2*min/h). The primary outcome was ABI, defined as abnormalities noted on brain computerized tomography (CT) or magnetic resonance imaging (MRI) obtained during or after ECMO therapy. Results: Eighteen of Twenty patients who underwent NIRS monitoring while on VA ECMO were included in analysis. Eleven patients (61%) experienced rScO2 desaturations. Patients with desaturations were more frequently female (73 vs. 14%, p = 0.05), had acute liver dysfunction (64 vs. 14%, p = 0.05), and higher peak total bilirubin (5.2 mg/dL vs. 1.4 mg/dL, p = 0.02). Six (33%) patients exhibited ABI, and had lower pre-ECMO Glasgow Coma Scale (GCS) scores (5 vs. 10, p = 0.03) and higher peak total bilirubin levels (7.3 vs. 1.4, p = 0.009). All ABI patients experienced rScO2 desaturation while 42% of patients without ABI experienced desaturation (p = 0.04). ABI patients had higher AUC rates than non-ABI patients (right hemisphere: 5.7 vs. 0, p = 0.01, left hemisphere: 119 vs. 0, p = 0.06), more desaturation events (13 vs. 0, p = 0.05), longer desaturation duration (2:33 vs. 0, p = 0.002), and more severe desaturation events with rScO2 < 40 (9 vs. 0, p = 0.05). Patients with ABI had lower GCS scores (post-ECMO initiation) before care withdrawal or discharge than those without ABI (10 vs. 15, p = 0.02). Conclusions: The presence and burden of cerebral desaturations noted on NIRS cerebral oximetry are associated with secondary neurologic injury in adults undergoing VA ECMO.
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Affiliation(s)
- Imad Khan
- Division of Neurocritical Care, Department of Neurology, University of Rochester School of Medicine, Rochester, NY, United States
| | - Mehboob Rehan
- Department of Medicine, Eastern Idaho Regional Medical Center, Idaho Falls, ID, United States
| | - Gunjan Parikh
- Section of Neurocritical Care and Emergency Neurology, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Christopher Zammit
- Division of Neurocritical Care, Department of Neurology, University of Rochester School of Medicine, Rochester, NY, United States
| | - Neeraj Badjatia
- Section of Neurocritical Care and Emergency Neurology, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Daniel Herr
- Division of Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Zachary Kon
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Charles Hogue
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, United States
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20
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Affiliation(s)
- P Ellul
- Gastroenterology, Mater dei Hospital, Tal Qroqq, Malta
| | - C Zammit
- Gastroenterology, Mater dei Hospital, Tal Qroqq, Malta
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21
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Drago G, Perrino C, Canepari S, Ruggieri S, L'Abbate L, Longo V, Colombo P, Frasca D, Balzan M, Cuttitta G, Scaccianoce G, Piva G, Bucchieri S, Melis M, Viegi G, Cibella F, Balzan M, Bilocca D, Borg C, Montefort S, Zammit C, Bucchieri S, Cibella F, Colombo P, Cuttitta G, Drago G, Ferrante G, L'Abbate L, Grutta SL, Longo V, Melis MR, Ruggieri S, Viegi G, Minardi R, Piva G, Ristagno R, Rizzo G, Scaccianoce G. Relationship between domestic smoking and metals and rare earth elements concentration in indoor PM 2.5. Environ Res 2018; 165:71-80. [PMID: 29674239 DOI: 10.1016/j.envres.2018.03.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [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: 11/25/2017] [Revised: 02/09/2018] [Accepted: 03/15/2018] [Indexed: 06/08/2023]
Abstract
Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke-related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM2.5 and heavy metals, 73 children were investigated by parental questionnaire and skin prick tests. The houses of residence of 41 "cases" and 32 "controls" (children with and without respiratory symptoms, respectively) were evaluated by 48-h PM2.5 indoor/outdoor monitoring. PM2.5 mass concentration was determined by gravimetry; the extracted and mineralized fractions of elements (As, Cd, Ce, La, Mn, Pb, Sb, Sr, Tl) were evaluated by ICP-MS. PM2.5 and Ce, La, Cd, and Tl indoor concentrations were higher in smoker dwellings. When corrected for confounding factors, PM2.5, Ce, La, Cd, and Tl were associated with more likely presence of respiratory symptoms in adolescents. We found that: i) indoor smoking is associated with increased levels of PM2.5, Ce, La, Cd, and Tl and ii) the latter with increased presence of respiratory symptoms in children.
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Affiliation(s)
- Gaspare Drago
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Cinzia Perrino
- National Research Council of Italy, Institute of Atmospheric Pollution Research, Rome, Italy
| | - Silvia Canepari
- Department of Chemistry, Sapienza University of Rome, Rome, Italy
| | - Silvia Ruggieri
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Luca L'Abbate
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Valeria Longo
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Paolo Colombo
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Daniele Frasca
- National Research Council of Italy, Institute of Atmospheric Pollution Research, Rome, Italy; Department of Chemistry, Sapienza University of Rome, Rome, Italy
| | - Martin Balzan
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Giuseppina Cuttitta
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Gianluca Scaccianoce
- Department of Energy, Information Engineering and Mathematical Models, University of Palermo, Palermo, Italy
| | | | - Salvatore Bucchieri
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Mario Melis
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Giovanni Viegi
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Fabio Cibella
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy.
| | - Martin Balzan
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - David Bilocca
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Charles Borg
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Stephen Montefort
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | | | - Salvatore Bucchieri
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Fabio Cibella
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Paolo Colombo
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Giuseppina Cuttitta
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Gaspare Drago
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Giuliana Ferrante
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Luca L'Abbate
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Stefania La Grutta
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Valeria Longo
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Mario R Melis
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Silvia Ruggieri
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Giovanni Viegi
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Remo Minardi
- ASP Caltanissetta - Health District of Gela, Italy
| | | | | | - Gianfranco Rizzo
- Department of Energy, Information Engineering and Mathematical Models, University of Palermo, Palermo, Italy
| | - Gianluca Scaccianoce
- Department of Energy, Information Engineering and Mathematical Models, University of Palermo, Palermo, Italy
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22
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George BP, Pieters TA, Zammit C, Sheth KN, Bhalla T. Abstract TP43: Trends in Interhospital Transfers and Mechanical Thrombectomy for Acute Ischemic Stroke. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tp43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Stroke care in the US is becoming increasingly regionalized. Many patients undergo interhospital transfer to obtain access to specialized, time-sensitive interventions such as mechanical thrombectomy.
Methods:
We used the stratified survey design of the US Nationwide Inpatient Sample, 2009-2014, to examine nationwide trends in interhospital transfers for ischemic stroke and the relationship between transfers and thrombectomy.
International Classification of Disease—Ninth Revision
diagnosis and procedure codes were used to identify acute stroke admissions and inpatient procedures (tissue plasminogen activator [tPA] administration and thrombectomy), respectively. The analysis was restricted to hospitals with the capabilities to perform thrombectomy. Trends were assessed using a Cochran-Armitage test.
Results:
From 2009 to 2014, an estimated 759,648 ischemic stroke admissions were identified within hospitals offering thrombectomy (102,674 in 2009; 154,280 in 2014). The proportion of stroke admissions to these hospitals that underwent interhospital transfer prior to arrival increased from 13.5% (n=13,811) in 2009 to 18.9% (n=19,175) in 2014 (
P
trend<0.001). Compared to “front door” patients, transfers were more likely to receive tPA (10.7% vs. 26.5%;
P
<0.001) and thrombectomy (2.7% vs. 5.7%;
P
<0.001). The proportion of transfers that received thrombectomy increased from 4.5% (n=625) to 6.0% (n=1,745) from 2009 to 2014 (
P
trend=0.016). Approximately 30% of patients receiving thrombectomy for ischemic stroke were transferred from another acute care facility (n=7,328). Among patients receiving tPA, transferred patients were slightly less likely to receive thrombectomy compared to those arriving by “front door” at thrombectomy performing centers (13.9% vs. 15.4%;
P
=0.004).
Conclusions:
From 2009 to 2014, interhospital stroke transfers to thrombectomy performing hospitals more than doubled. For every ~5 additional stroke transfers over the time period examined, one additional transferred patient received thrombectomy. As stroke systems of care continue to evolve across the US, the optimization of stroke transfers presents an opportunity to increase access to meaningful interventions such as thrombectomy.
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Affiliation(s)
| | | | - Christopher Zammit
- Div of Neurocritical Care, Dept of Neurology, Univ of Rochester, Rochester, NY
| | - Kevin N Sheth
- Dept of Neurology, Yale New Haven Hosp, New Haven, CT
| | - Tarun Bhalla
- Dept of Neurosurgery, Univ of Rochester, Rochester, NY
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23
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Mulligan A, Moriswala R, Scholes E, Zammit C, Cox N, Neil C. Effectiveness of Unit Education Regarding Guideline Changes in a Single Centre: Iron Replacement in Heart Failure. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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24
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Zammit C, Scholes E, Seman M, Tsang D, Lethlean P, Mateevici C, Neil C. Home-Based Administration of Intravenous Frusemide as an Alternative to Hospitalisation for Patients With Decompensated Heart Failure: A Collaborative Patient-Centred Approach. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Mulligan A, Moriswala R, Scholes E, Zammit C, Cox N, Neil C. Absolute and Functional Iron Deficiency in Hospitalised Patients with Heart Failure: Effect on All-Cause Readmission. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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26
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Ruggieri S, Drago G, Longo V, Colombo P, Balzan M, Bilocca D, Zammit C, Montefort S, Scaccianoce G, Cuttitta G, Viegi G, Cibella F. Sensitization to dust mite defines different phenotypes of asthma: A multicenter study. Pediatr Allergy Immunol 2017; 28:675-682. [PMID: 28783215 DOI: 10.1111/pai.12768] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Indoor allergens are risk factors for asthma: Thus, the characterization of indoor air quality is important for studying environment-health relationships in children. In particular, Dermatophagoides pteronyssinus is the dominant allergen for asthma. We cross-sectionally investigated the relationships among respiratory symptoms and function, airway inflammation, allergen sensitization, and indoor allergen concentration. METHODS One hundred and thirty-two children aging 10-14 years and living in a Southern Mediterranean area were evaluated by parental questionnaires. Spirometry, exhaled nitric oxide (FeNO), skin prick tests, total, and specific serum IgE analyses were performed along with the evaluation of home dust samples for the content in Der p 1 allergen. Three clusters were created on the basis of the presence/absence of wheeze in the last 12 months (Wh12m) and Der p 1-specific IgE level. RESULTS Cluster 1 (Wh12m+/high Der p 1 IgE) presented higher FeNO and poorer pulmonary function (lower FEV1 and FEF25%-75% ), while its symptom score was not different from Cluster 2 (Wh12m+/low Der p 1 IgE). Cluster 3 (Wh12m-/low IgE) showed the lowest FeNO values and pulmonary function similar to Cluster 2. Within Cluster 1, both Der p 1-specific IgE and FeNO were positively correlated with dust Der p 1. CONCLUSIONS Similar asthma phenotypes may occur in children despite differences in their atopic state. In atopic children, sensitizing allergens in the indoor environment may increase airway inflammation worsening pulmonary function. Moreover, environmental exposures may contribute to the development of asthma-like symptoms also in the absence of atopic sensitization, thus contributing to asthma overdiagnosis.
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Affiliation(s)
- Silvia Ruggieri
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Gaspare Drago
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Valeria Longo
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Paolo Colombo
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Martin Balzan
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - David Bilocca
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | | | - Stephen Montefort
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Gianluca Scaccianoce
- Department of Energy, Information Engineering and Mathematical Models, University of Palermo, Palermo, Italy
| | - Giuseppina Cuttitta
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Giovanni Viegi
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Fabio Cibella
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
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Mulligan A, Seman M, Abramowski R, Mulkhtar AO, Zammit C, Scholes E, Long C, Neil C, Cox N. A ‘Cardiogeriatric Model’ of Care in Acute Decompensated Heart Failure: Implementation of a Multidisciplinary Approach Impacting 12-Month Readmissions in Complex Patients. Heart Lung Circ 2017. [DOI: 10.1016/j.hlc.2017.06.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Affiliation(s)
- Natalie P Kreitzer
- Neurocritical Care and Neurovascular Emergencies, University of Cincinnati, Cincinnati, OH, USA.
| | - Jordan Bonomo
- Neurosurgery/Neurocritical Care, University of Cincinnati, Cincinnati, OH, USA
| | - Daniel Kanter
- Division of Neurocritical Care, University of Cincinnati, Cincinnati, OH, USA
| | - Christopher Zammit
- Neurosurgery/Neurocritical Care, University of Cincinnati, Cincinnati, OH, USA
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Mulligan A, Seman M, Abramowski R, Zammit C, Scholes E, Long C, Janus E, Cowie K, Cox N, Neil C. A ‘Cardiogeriatric Model’ of Care in Acute Decompensated Heart Failure: Implementation of a Multidisciplinary Approach, Impacting 30-Day Hospital Readmission. Heart Lung Circ 2016. [DOI: 10.1016/j.hlc.2016.06.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Schmid P, Pinder SE, Bundred N, Wheatley D, Macaskill J, Zammit C, Hu J, Price R, Shia A, Lim L, Parker P, Molinero L, Yu J, O'Brien C, Wilson T, Savage H, Derynck M, Lackner MR, Amler L, Purushotham A, Thompson A, Gendreau S. Abstract P5-13-01: Transcript analysis of PI3K and immune-related genes and gene signatures in the pre- and post-treatment samples from the window of opportunity study of anastrozole and anastrozole with pictilisib (GDC-0941) in patients with HR-positive early breast cancer (OPPORTUNE study). Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p5-13-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The OPPORTUNE Study randomized postmenopausal patients (pts) to receive 2-week preoperative treatment with anastrozole (ANA) plus pictilisib ("ANA+PIC" arm) or ANA alone. Patients had newly diagnosed, operable, ER+, HER2- invasive breast cancer of ≥1 cm size. The primary outcome at interim analysis (n=70) revealed that the addition of PIC significantly increased the anti-proliferative response to ANA as measured by reduction in Ki67 immunohistochemistry (IHC). Multivariate analyses suggested benefit of PIC for patients with luminal B disease (Schmid et al. SABCS 2014).
Methods: RNA expression analysis of ∼800 breast cancer-related genes was performed on patients analyzed at the interim analysis, including 14 (ANA) and 20 (ANA+PIC) patients with matched pre- and post- treatment paired tumour samples using the nCounter platform (NanoString). Differential expression of individual genes by arm was assessed using paired and moderated t-tests and statistical significance assessed through false discovery rate (FDR). Ingenuity Pathway Analysis (IPA) of differentially expressed transcripts identified pathways of relevance. Protein expression was analyzed by reverse protein array ( RPPA) in pre- and post-treatment samples.
Results: In an unsupervised analysis, down-regulation of genes associated with ER signaling was observed in patients who received single-agent ANA and ANA+PIC, which included genes that regulate the cell cycle, cell death, survival, growth and proliferation and known ER target genes (e.g., PGR, GREB1). In addition, transcripts related to growth factor signaling pathway appeared to be specifically modulated in the ANA+PIC arm, possibly via the upregulation of the expression of RTK ligands. There were no clear changes in PI3K-related phosphoproteins (e.g., AKT, S6, 4E-BP1) in the post-treatment samples by RPPA. However, known PI3K-regulated genes, IRS2 and PIK3IP1, were upregulated in the post-treatment samples and a composite PI3K gene expression signature score (O'Brien et al. 2010) was reduced in both study arms following treatment. This PI3K signature was associated with pre-treatment luminal B status (n=27) and, consistent with this finding, the baseline PI3K gene signature score in the ANA arm, but not the ANA+PIC arm, was inversely associated with the decrease in post treatment Ki67. The tumor immune microenvironment was analyzed though the use of composite gene sets. In our initial observations, analysis of pre- and post-treatment samples showed that 2-week treatment with ANA resulted in a modest increase in transcripts associated with multiple immune signatures, which was further enhanced by the addition of PIC.
Conclusions: Gene expression analysis of pre- and post-treatment samples in the OPPORTUNE study demonstrates on-target inhibition of ER and PI3K signaling networks. The analysis of additional paired samples is in progress to further assess if 2-weeks of treatment with a regimen containing an AI in patients with early breast cancer impacts the tumor immune microenvironment.
Citation Format: Schmid P, Pinder SE, Bundred N, Wheatley D, Macaskill J, Zammit C, Hu J, Price R, Shia A, Lim L, Parker P, Molinero L, Yu J, O'Brien C, Wilson T, Savage H, Derynck M, Lackner MR, Amler L, Purushotham A, Thompson A, Gendreau S. Transcript analysis of PI3K and immune-related genes and gene signatures in the pre- and post-treatment samples from the window of opportunity study of anastrozole and anastrozole with pictilisib (GDC-0941) in patients with HR-positive early breast cancer (OPPORTUNE study). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-13-01.
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Affiliation(s)
- P Schmid
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - SE Pinder
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - N Bundred
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - D Wheatley
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - J Macaskill
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - C Zammit
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - J Hu
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - R Price
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - A Shia
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - L Lim
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - P Parker
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - L Molinero
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - J Yu
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - C O'Brien
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - T Wilson
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - H Savage
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - M Derynck
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - MR Lackner
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - L Amler
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - A Purushotham
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - A Thompson
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - S Gendreau
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
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Jenkins V, Harder H, Cercingani M, Whiteley-Jones H, Thwaites R, Mullen L, Harrison N, Davies K, Zammit C, Sacre S. P084 Feasibility study to examine underlying mechanisms for “Chemo Fog”. Breast 2015. [DOI: 10.1016/s0960-9776(15)70129-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Bains SK, Peters AM, Zammit C, Ryan N, Ballinger J, Glass DM, Allen S, Stanton AWB, Mortimer PS, Purushotham AD. Global abnormalities in lymphatic function following systemic therapy in patients with breast cancer. Br J Surg 2015; 102:534-40. [DOI: 10.1002/bjs.9766] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/20/2014] [Accepted: 12/04/2014] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Breast cancer-related lymphoedema (BCRL) is a result of interaction between several pathophysiological processes, and is not simply a ‘stopcock’ effect resulting from removal of axillary lymph nodes. The aim of this study was to test the hypothesis that there is a constitutional ‘global’ lymphatic dysfunction in patients who develop BCRL.
Methods
Lower-limb lymphoscintigraphy was performed in 30 women who had undergone axillary lymph node dissection at least 3 years previously, of whom 15 had BCRL and 15 did not. No patient had any clinical abnormality of the lower limb. The control group comprised 24 women with no history of cancer or lower-limb lymphoedema. 99mTc-Nanocoll was injected subcutaneously into the first webspace of each foot, followed by whole-body imaging. Scans were reported as abnormal if there was delay in lymph transport or rerouting through skin or deep system. Quantification was expressed as the percentage injected activity accumulating in ilioinguinal nodes.
Results
Mean(s.d.) ilioinguinal nodal accumulation at 150 min was significantly lower in women with BCRL than in those without (2·7(2·5) versus 5·9(4·8) per cent respectively; P = 0·006). Abnormal findings on lower-limb lymphoscintigraphy were observed in 17 of the 30 patients: ten of the 15 women who had BCRL and seven of the 15 who did not. None of the 24 control subjects had abnormal scan findings.
Conclusion
Women with BCRL had reduced lower-limb lymph drainage, supporting the hypothesis of a predisposition to BCRL. A surprisingly high proportion of patients with breast cancer also demonstrated lymphatic dysfunction, despite clinically normal lower limbs. Possible explanations could be a systemic effect of breast cancer or its treatment, or an unidentified association between breast cancer and lymphatic dysfunction. Registration number: ISRCTN84866416 (http://www.isrctn.com).
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Affiliation(s)
- S K Bains
- Division of Cancer Studies, King's College London, St George's, University of London, London, UK
- Department of Breast Surgery, St George's, University of London, London, UK
| | - A M Peters
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - C Zammit
- Department of Breast Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - N Ryan
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - J Ballinger
- Department of Nuclear Medicine, Guy's and St Thomas' NHS Foundation Trust, St George's, University of London, London, UK
| | - D M Glass
- Department of Molecular Imaging Centre, Harley Street Clinic, St George's, University of London, London, UK
| | - S Allen
- Department of Nuclear Medicine, Guy's and St Thomas' NHS Foundation Trust, St George's, University of London, London, UK
| | - A W B Stanton
- Department of Clinical Sciences, St George's, University of London, London, UK
| | - P S Mortimer
- Department of Clinical Sciences, St George's, University of London, London, UK
| | - A D Purushotham
- Division of Cancer Studies, King's College London, St George's, University of London, London, UK
- Department of Breast Surgery, St George's, University of London, London, UK
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Bains SK, Stanton AWB, Cintolesi V, Ballinger J, Allen S, Zammit C, Levick JR, Mortimer PS, Peters AM, Purushotham AD. A constitutional predisposition to breast cancer-related lymphoedema and effect of axillary lymph node surgery on forearm muscle lymph flow. Breast 2014; 24:68-74. [PMID: 25491189 DOI: 10.1016/j.breast.2014.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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: 07/29/2014] [Revised: 08/13/2014] [Accepted: 11/19/2014] [Indexed: 11/24/2022] Open
Abstract
AIM The aims of this prospective study were (a) to examine the relationship between pre-operative muscle lymph flow and the predisposition to BCRL in women treated by axillary nodal surgery for breast cancer; and (b) to test the 'stopcock' hypothesis that axillary lymph node surgery impairs forearm lymph flow in the short term. METHODS (99m)Tc-nanocoll was injected intramuscularly into both forearms of women undergoing surgery for breast cancer. Lymphatic clearance rate constant, k, representing lymph flow per unit interstitial fluid volume, was measured as the fractional disappearance rate of radioactivity from the depot site by gamma camera imaging. Axillary lymph node activity was calculated as percentage injected activity. BCRL was assessed by clinical examination and upper limb perometry. RESULTS Of 38 pre-operative women, 33 attended at 8 ± 6 weeks post-operatively and 31 at 58 ± 9 weeks post-operatively. Seven patients (18%) developed BCRL. Prior to surgery the BCRL-destined patients had a higher mean k (0.0962 ± 0.034%/min) than non-BCRL patients (0.0830 ± 0.019%/min) (p = 0.10, unpaired t test). Post-operative k values were not significantly different from pre-operative, in either the ipsilateral (operated) or contralateral limb. Also, post-operative k values did not differ significantly between both upper limbs. Furthermore, there was no significant difference between pre- and post-operative axillary activity. CONCLUSION Patients who develop BCRL have high lymph flow pre-surgery, which may predispose them to lymphatic overload and failure. Axillary lymph node surgery has no early, measurable effect on forearm muscle lymph flow despite surgical disruption of routes of lymph drainage.
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Affiliation(s)
- S K Bains
- Division of Cancer Studies, King's College London, United Kingdom; Guy's & St Thomas' NHS Foundation Trust, United Kingdom
| | - A W B Stanton
- Clinical Sciences, St George's, University of London, United Kingdom
| | - V Cintolesi
- Clinical Sciences, St George's, University of London, United Kingdom
| | - J Ballinger
- Guy's & St Thomas' NHS Foundation Trust, United Kingdom
| | - S Allen
- Guy's & St Thomas' NHS Foundation Trust, United Kingdom
| | - C Zammit
- Department of Breast Surgery, Brighton and Sussex University Hospitals NHS Trust, United Kingdom
| | - J R Levick
- Clinical Sciences, St George's, University of London, United Kingdom
| | - P S Mortimer
- Clinical Sciences, St George's, University of London, United Kingdom
| | - A M Peters
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, United Kingdom
| | - A D Purushotham
- Division of Cancer Studies, King's College London, United Kingdom; Guy's & St Thomas' NHS Foundation Trust, United Kingdom.
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Laureys G, Valentino M, Demol F, Zammit C, Muscat R, Cambron M, Kooijman R, De Keyser J. β₂-adrenergic receptors protect axons during energetic stress but do not influence basal glio-axonal lactate shuttling in mouse white matter. Neuroscience 2014; 277:367-74. [PMID: 25064060 DOI: 10.1016/j.neuroscience.2014.07.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [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: 04/28/2014] [Revised: 06/30/2014] [Accepted: 07/16/2014] [Indexed: 10/25/2022]
Abstract
In vitro studies have demonstrated that β2-adrenergic receptor activation stimulates glycogen degradation in astrocytes, generating lactate as a potential energy source for neurons. Using in vivo microdialysis in mouse cerebellar white matter we demonstrate continuous axonal lactate uptake and glial-axonal metabolic coupling of glutamate/lactate exchange. However, this physiological lactate production was not influenced by activation (clenbuterol) or blocking (ICI 118551) of β2-adrenergic receptors. In two-photon imaging experiments on ex vivo mouse corpus callosum subjected to aglycemia, β2-adrenergic activation rescued axons, whereas inhibition of axonal lactate uptake by α-cyano-4-hydroxycinnamic acid (4-CIN) was associated with severe axonal loss. Our results suggest that axonal protective effects of glial β2-adrenergic receptor activation are not mediated by enhanced lactate production.
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Affiliation(s)
- G Laureys
- Department of Neurology, University Hospital Brussels, Center for Neurosciences, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - M Valentino
- Department of Physiology and Biochemistry, Faculty of Medicine & Surgery, University of Malta, Msida MSD 2080, Malta
| | - F Demol
- Department of Neurology, University Hospital Brussels, Center for Neurosciences, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - C Zammit
- Department of Anatomy, Faculty of Medicine & Surgery, University of Malta, Msida MSD 2080, Malta
| | - R Muscat
- Department of Physiology and Biochemistry, Faculty of Medicine & Surgery, University of Malta, Msida MSD 2080, Malta
| | - M Cambron
- Department of Neurology, University Hospital Brussels, Center for Neurosciences, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - R Kooijman
- Experimental Pharmacology, Center for Neurosciences, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - J De Keyser
- Department of Neurology, University Hospital Brussels, Center for Neurosciences, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium; Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
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35
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Hathaway CF, Zammit C, Shaheed S, Rubin G, O'Brien J. PB.02: Magnetic resonance imaging axilla: friend or foe? Breast Cancer Res 2013. [PMCID: PMC3981618 DOI: 10.1186/bcr3504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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36
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Zammit C, Knight WA. Severe traumatic brain injury in adults. Emerg Med Pract 2013; 15:1-28. [PMID: 23452439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 02/10/2013] [Indexed: 06/01/2023]
Abstract
Traumatic brain injury is the most common cause of death and disability in young people, with an annual financial burden of over $50 billion per year in the United States. Traumatic brain injury is defined by both the initial primary injury and the subsequent secondary injuries. Fundamental to emergency department management is ensuring brain perfusion, oxygenation, and preventing even brief or transient episodes of hypotension, hypoxia, and hypocapnia. Cerebral perfusion pressure is a function of intracranial pressure and systemic blood pressure, and it must be monitored and maintained. Current research is devoted towards the prevention and treatment of secondary injury. The emergency clinician must be vigilant in maintaining homeostasis while coordinating the downstream care of the patient, including the intensive care unit and/or the operating room.
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Affiliation(s)
- Christopher Zammit
- Columbia University College of Physicians and Surgeons, New York, NY, USA
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Shaheed S, Ugolini F, Yelland A, Zammit C. 504 Observational Study and Evaluation of Blue Dye-assisted Axillary Node Sampling for Axillary Staging in Early Breast Cancer. Eur J Cancer 2012. [DOI: 10.1016/s0959-8049(12)70569-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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38
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Jenkins V, Harder H, Babar M, Merry S, Newbury S, Kissin M, Zammit C. A pilot study to examine the experiences and attitudes of women with breast cancer towards one versus two-step axillary surgery. Breast 2012; 21:72-6. [DOI: 10.1016/j.breast.2011.08.125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 08/08/2011] [Indexed: 11/24/2022] Open
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39
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Jones EF, Zammit C, Rubin G. Should we be using nonscreening symptomatic units' mammogram machines for screening? Women's attitudes and factors likely to affect whether they attend. Breast Cancer Res 2011. [PMCID: PMC3238276 DOI: 10.1186/bcr2991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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40
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Shaheed S, Ugolini F, Yelland A, Zammit C. Evaluation of the reliability of blue dye-assisted axillary node sampling in early breast cancer. Eur J Surg Oncol 2011. [DOI: 10.1016/j.ejso.2011.08.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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41
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Zammit R, Zammit C. Patient understanding of medical terminology and the role of the Multidisiplinary Team (MDT) in breast cancer care. Eur J Surg Oncol 2011. [DOI: 10.1016/j.ejso.2011.08.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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42
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Rathinaezhil R, Zammit C. Re-excision to clear margins after breast conserving surgery for Breast Cancer -what is adequate? Eur J Surg Oncol 2011. [DOI: 10.1016/j.ejso.2011.08.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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43
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Fabbri A, Bonijoly D, Bouc O, Bureau G, Castagnac C, Chapuis F, Galiègue X, Laude A, Le Gallo Y, Grataloup S, Ricci O, Royer-Adnot J, Zammit C. From geology to economics: Technico-economic feasibility of a biofuel-CCS system. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.egypro.2011.02.197] [Citation(s) in RCA: 7] [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: 10/18/2022]
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44
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Spurling KJ, Zammit C, Lozewicz S. Mains-powered hypoxic gas generation: a cost-effective and safe method to evaluate patients at risk from hypoxia during air travel. Thorax 2010; 66:731-2. [DOI: 10.1136/thx.2010.141655] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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45
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Rathinaezhil R, Zammit C. Role of preoperative chest X-ray (CXR) in patients undergoing mastectomy for primary invasive breast cancer – Is it worthwhile? Eur J Surg Oncol 2010. [DOI: 10.1016/j.ejso.2010.08.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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46
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Abstract
The obesity epidemic is a global problem, which is set to increase over time. However, the effects of obesity on the respiratory system are often underappreciated. In this review, we will discuss the mechanical effects of obesity on lung physiology and the function of adipose tissue as an endocrine organ producing systemic inflammation and effecting central respiratory control. Obesity plays a key role in the development of obstructive sleep apnea and obesity hypoventilation syndrome. Asthma is more common and often harder to treat in the obese population, and in this study, we review the effects of obesity on airway inflammation and respiratory mechanics. We also discuss the compounding effects of obesity on chronic obstructive pulmonary disease (COPD) and the paradoxical interaction of body mass index and COPD severity. Many practical challenges exist in caring for obese patients, and we highlight the complications faced by patients undergoing surgical procedures, especially given the increased use of bariatric surgery. Ultimately, a greater understanding of the effects of obesity on the respiratory disease and the provision of adequate health care resources is vital in order to care for this increasingly important patient population.
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Affiliation(s)
- Christopher Zammit
- Sleep and Ventilation Unit, Department of Respiratory Medicine, North Middlesex University Hospital, London, UK
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47
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Rubin G, Zammit C. Breast cancer in 35 to 39 year olds and imaging: is changing to ultrasound without mammography going to be safe? What are the workload implications? Breast Cancer Res 2010. [PMCID: PMC2978881 DOI: 10.1186/bcr2717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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48
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Rathinaezhil R, Allen K, Taylor M, Berresford A, Yelland A, Zammit C. Ultrasound of axilla - does size of the lymph node metastasis matter in breast cancer? Eur J Surg Oncol 2009. [DOI: 10.1016/j.ejso.2009.07.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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49
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Rathinaezhil R, Taylor N, Yelland A, Zammit C. Is there a role for Primary Endocrine Treatment (PET) in elderly patients (>75years) diagnosed with Breast Cancer? Eur J Surg Oncol 2008. [DOI: 10.1016/j.ejso.2008.06.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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50
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Debourdeau P, Bory P, Zammit C, Pavic M, Colle B. Lipothymie récidivante inexpliquée: penser au syndrome d'hyperperméabilité capillaire idiopathique. Rev Med Interne 2007; 28:711-3. [PMID: 17321012 DOI: 10.1016/j.revmed.2007.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Revised: 01/24/2007] [Accepted: 01/24/2007] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Systemic capillary leak syndrome (SCLS) is a rare disorder characterized by recurrent spontaneous episodes of hypovolaemic shock due to marked plasma shifts from the intravascular to the extravascular space. It presents as the characteristic triad of hypotension, haemoconcentration and hypoalbuminemia. CASE REPORT We describe a patient with SCLS with recurrent lipothymia who presented first with delayed oedema that was thought to be due to orlistat treatment. On the second episode the patient was seen with a pulmonary hypertension when plasma came back into vessels. On the third time the characteristic triad led to the diagnosis of SCLS. DISCUSSION SCLS should be considered in the differential diagnosis of recurrent hypovolemic shock without identifiable cause. Nevertheless, symptoms may be restricted to sole lipothymia or transient oedema or delayed hypoalbuminemia rendering the diagnosis difficult.
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Affiliation(s)
- P Debourdeau
- Service de médecine interne, hôpital Desgenettes, 108 boulevard Pinel, 69003 Lyon, France.
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