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Beringer A, Thiam N, Molle J, Bartosch B, Miossec P. Synergistic effect of interleukin-17 and tumour necrosis factor-α on inflammatory response in hepatocytes through interleukin-6-dependent and independent pathways. Clin Exp Immunol 2018; 193:221-233. [PMID: 29676779 DOI: 10.1111/cei.13140] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 12/25/2022] Open
Abstract
The proinflammatory cytokines interleukin (IL)-17 and tumour necrosis factor (TNF)-α are targets for treatment in many chronic inflammatory diseases. Here, we examined their role in liver inflammatory response compared to that of IL-6. Human hepatoma cells (HepaRG, Huh7.5 and HepG2 cells) and primary human hepatocytes (PHH) were cultured with IL-6, IL-17 and/or TNF-α. To determine the contribution of the IL-6 pathway in the IL-17/TNF-α-mediated effect, an anti-IL-6 receptor antibody was used. IL-17 and TNF-α increased in synergy IL-6 secretion by HepaRG cells and PHH but not by Huh7.5 and HepG2 cells. This IL-17/TNF-α synergistic cooperation enhanced the levels of C-reactive protein (CRP) and aspartate aminotransferase (ASAT) in HepaRG cell and PHH cultures through the induction of IL-6. IL-17/TNF-α also up-regulated IL-8, monocyte chemoattractant protein (MCP)-1 and chemokine (C-C motif) ligand 20 (CCL20) chemokines in synergy through an IL-6-independent pathway. Interestingly, first exposure to IL-17, but not to TNF-α, was crucial for the initiation of the IL-17/TNF-α synergistic effect on IL-6 and IL-8 production. In HepaRG cells, IL-17 enhanced IL-6 mRNA stability resulting in increased IL-6 protein levels. The IL-17A/TNF-α synergistic effect on IL-6 and IL-8 induction was mediated through the activation of extracellular signal-regulated kinase (ERK)-mitogen-activated protein kinase, nuclear factor-κB and/or protein kinase B (Akt)-phosphatidylinositol 3-kinase signalling pathways. Therefore, the IL-17/TNF-α synergistic interaction mediates systemic inflammation and cell damage in hepatocytes mainly through IL-6 for CRP and ASAT induction. Independently of IL-6, the IL-17A/TNF-α combination may also induce immune cell recruitment by chemokine up-regulation. IL-17 and/or TNF-α neutralization can be a promising therapeutic strategy to control both systemic inflammation and liver cell attraction.
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Affiliation(s)
- A Beringer
- Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon
| | - N Thiam
- Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon
| | - J Molle
- Cancer Research Center Lyon, INSERM U1052 and CNRS 5286, University of Lyon, Lyon, France
| | - B Bartosch
- Cancer Research Center Lyon, INSERM U1052 and CNRS 5286, University of Lyon, Lyon, France
| | - P Miossec
- Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon
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Lovell K, Bower P, Gellatly J, Byford S, Bee P, McMillan D, Arundel C, Gilbody S, Gega L, Hardy G, Reynolds S, Barkham M, Mottram P, Lidbetter N, Pedley R, Molle J, Peckham E, Knopp-Hoffer J, Price O, Connell J, Heslin M, Foley C, Plummer F, Roberts C. Clinical effectiveness, cost-effectiveness and acceptability of low-intensity interventions in the management of obsessive-compulsive disorder: the Obsessive-Compulsive Treatment Efficacy randomised controlled Trial (OCTET). Health Technol Assess 2018; 21:1-132. [PMID: 28681717 DOI: 10.3310/hta21370] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The Obsessive-Compulsive Treatment Efficacy randomised controlled Trial emerged from a research recommendation in National Institute for Health and Care Excellence obsessive-compulsive disorder (OCD) guidelines, which specified the need to evaluate cognitive-behavioural therapy (CBT) treatment intensity formats. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of two low-intensity CBT interventions [supported computerised cognitive-behavioural therapy (cCBT) and guided self-help]: (1) compared with waiting list for high-intensity CBT in adults with OCD at 3 months; and (2) plus high-intensity CBT compared with waiting list plus high-intensity CBT in adults with OCD at 12 months. To determine patient and professional acceptability of low-intensity CBT interventions. DESIGN A three-arm, multicentre, randomised controlled trial. SETTING Improving Access to Psychological Therapies services and primary/secondary care mental health services in 15 NHS trusts. PARTICIPANTS Patients aged ≥ 18 years meeting Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria for OCD, on a waiting list for high-intensity CBT and scoring ≥ 16 on the Yale-Brown Obsessive Compulsive Scale (indicative of at least moderate severity OCD) and able to read English. INTERVENTIONS Participants were randomised to (1) supported cCBT, (2) guided self-help or (3) a waiting list for high-intensity CBT. MAIN OUTCOME MEASURES The primary outcome was OCD symptoms using the Yale-Brown Obsessive Compulsive Scale - Observer Rated. RESULTS Patients were recruited from 14 NHS trusts between February 2011 and May 2014. Follow-up data collection was complete by May 2015. There were 475 patients randomised: supported cCBT (n = 158); guided self-help (n = 158) and waiting list for high-intensity CBT (n = 159). Two patients were excluded post randomisation (one supported cCBT and one waiting list for high-intensity CBT); therefore, data were analysed for 473 patients. In the short term, prior to accessing high-intensity CBT, guided self-help demonstrated statistically significant benefits over waiting list, but these benefits did not meet the prespecified criterion for clinical significance [adjusted mean difference -1.91, 95% confidence interval (CI) -3.27 to -0.55; p = 0.006]. Supported cCBT did not demonstrate any significant benefit (adjusted mean difference -0.71, 95% CI -2.12 to 0.70). In the longer term, access to guided self-help and supported cCBT, prior to high-intensity CBT, did not lead to differences in outcomes compared with access to high-intensity CBT alone. Access to guided self-help and supported cCBT led to significant reductions in the uptake of high-intensity CBT; this did not seem to compromise patient outcomes at 12 months. Taking a decision-making approach, which focuses on which decision has a higher probability of being cost-effective, rather than the statistical significance of the results, there was little evidence that supported cCBT and guided self-help are cost-effective at the 3-month follow-up compared with a waiting list. However, by the 12-month follow-up, data suggested a greater probability of guided self-help being cost-effective than a waiting list from the health- and social-care perspective (60%) and the societal perspective (80%), and of supported cCBT being cost-effective compared with a waiting list from both perspectives (70%). Qualitative interviews found that guided self-help was more acceptable to patients than supported cCBT. Professionals acknowledged the advantages of low intensity interventions at a population level. No adverse events occurred during the trial that were deemed to be suspected or unexpected serious events. LIMITATIONS A significant issue in the interpretation of the results concerns the high level of access to high-intensity CBT during the waiting list period. CONCLUSIONS Although low-intensity interventions are not associated with clinically significant improvements in OCD symptoms, economic analysis over 12 months suggests that low-intensity interventions are cost-effective and may have an important role in OCD care pathways. Further research to enhance the clinical effectiveness of these interventions may be warranted, alongside research on how best to incorporate them into care pathways. TRIAL REGISTRATION Current Controlled Trials ISRCTN73535163. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 37. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Karina Lovell
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Peter Bower
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Judith Gellatly
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Sarah Byford
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Penny Bee
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Dean McMillan
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | | | - Simon Gilbody
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | - Lina Gega
- Social Work and Communities, Northumbria University, Newcastle, UK
| | - Gillian Hardy
- Department of Psychology, University of Sheffield, Sheffield, UK
| | | | - Michael Barkham
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Patricia Mottram
- Cheshire & Wirral Partnership, NHS Foundation Trust, Wallasey, UK
| | | | - Rebecca Pedley
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Jo Molle
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Emily Peckham
- Department of Health Sciences, University of York, York, UK
| | | | - Owen Price
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Janice Connell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Margaret Heslin
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Christopher Foley
- Centre for Biostatistics in the Institute of Population Health, University of Manchester, Manchester, UK
| | - Faye Plummer
- Department of Health Sciences, University of York, York, UK
| | - Christopher Roberts
- Centre for Biostatistics in the Institute of Population Health, University of Manchester, Manchester, UK
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Lovell K, Bower P, Gellatly J, Byford S, Bee P, McMillan D, Arundel C, Gilbody S, Gega L, Hardy G, Reynolds S, Barkham M, Mottram P, Lidbetter N, Pedley R, Molle J, Peckham E, Knopp-Hoffer J, Price O, Connell J, Heslin M, Foley C, Plummer F, Roberts C. Low-intensity cognitive-behaviour therapy interventions for obsessive-compulsive disorder compared to waiting list for therapist-led cognitive-behaviour therapy: 3-arm randomised controlled trial of clinical effectiveness. PLoS Med 2017; 14:e1002337. [PMID: 28654682 PMCID: PMC5486961 DOI: 10.1371/journal.pmed.1002337] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 05/26/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Obsessive-compulsive disorder (OCD) is prevalent and without adequate treatment usually follows a chronic course. "High-intensity" cognitive-behaviour therapy (CBT) from a specialist therapist is current "best practice." However, access is difficult because of limited numbers of therapists and because of the disabling effects of OCD symptoms. There is a potential role for "low-intensity" interventions as part of a stepped care model. Low-intensity interventions (written or web-based materials with limited therapist support) can be provided remotely, which has the potential to increase access. However, current evidence concerning low-intensity interventions is insufficient. We aimed to determine the clinical effectiveness of 2 forms of low-intensity CBT prior to high-intensity CBT, in adults meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for OCD. METHODS AND FINDINGS This study was approved by the National Research Ethics Service Committee North West-Lancaster (reference number 11/NW/0276). All participants provided informed consent to take part in the trial. We conducted a 3-arm, multicentre randomised controlled trial in primary- and secondary-care United Kingdom mental health services. All patients were on a waiting list for therapist-led CBT (treatment as usual). Four hundred and seventy-three eligible patients were recruited and randomised. Patients had a median age of 33 years, and 60% were female. The majority were experiencing severe OCD. Patients received 1 of 2 low-intensity interventions: computerised CBT (cCBT; web-based CBT materials and limited telephone support) through "OCFighter" or guided self-help (written CBT materials with limited telephone or face-to-face support). Primary comparisons concerned OCD symptoms, measured using the Yale-Brown Obsessive Compulsive Scale-Observer-Rated (Y-BOCS-OR) at 3, 6, and 12 months. Secondary outcomes included health-related quality of life, depression, anxiety, and functioning. At 3 months, guided self-help demonstrated modest benefits over the waiting list in reducing OCD symptoms (adjusted mean difference = -1.91, 95% CI -3.27 to -0.55). These effects did not reach a prespecified level of "clinically significant benefit." cCBT did not demonstrate significant benefit (adjusted mean difference = -0.71, 95% CI -2.12 to 0.70). At 12 months, neither guided self-help nor cCBT led to differences in OCD symptoms. Early access to low-intensity interventions led to significant reductions in uptake of high-intensity CBT over 12 months; 86% of the patients allocated to the waiting list for high-intensity CBT started treatment by the end of the trial, compared to 62% in supported cCBT and 57% in guided self-help. These reductions did not compromise longer-term patient outcomes. Data suggested small differences in satisfaction at 3 months, with patients more satisfied with guided self-help than supported cCBT. A significant issue in the interpretation of the results concerns the level of access to high-intensity CBT before the primary outcome assessment. CONCLUSIONS We have demonstrated that providing low-intensity interventions does not lead to clinically significant benefits but may reduce uptake of therapist-led CBT. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number (ISRCTN) Registry ISRCTN73535163.
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Affiliation(s)
- Karina Lovell
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- * E-mail:
| | - Peter Bower
- NIHR School for Primary Care Research, University of Manchester, Manchester, United Kingdom
| | - Judith Gellatly
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Sarah Byford
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Penny Bee
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Dean McMillan
- Hull York Medical School & Department of Health Sciences, University of York, York, United Kingdom
| | - Catherine Arundel
- Department of Health Sciences, University of York, York, United Kingdom
| | - Simon Gilbody
- Hull York Medical School & Department of Health Sciences, University of York, York, United Kingdom
| | - Lina Gega
- Hull York Medical School & Department of Health Sciences, University of York, York, United Kingdom
| | - Gillian Hardy
- Centre for Psychological Services Research, Department of Psychology, University of Sheffield, Sheffield, United Kingdom
| | - Shirley Reynolds
- School of Psychology, University of Reading, Reading, United Kingdom
| | - Michael Barkham
- Centre for Psychological Services Research, Department of Psychology, University of Sheffield, Sheffield, United Kingdom
| | - Patricia Mottram
- Cheshire & Wirral Partnership, NHS Foundation Trust, Wallasey, United Kingdom
| | | | - Rebecca Pedley
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jo Molle
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Emily Peckham
- Department of Health Sciences, University of York, York, United Kingdom
| | - Jasmin Knopp-Hoffer
- NIHR School for Primary Care Research, University of Manchester, Manchester, United Kingdom
| | - Owen Price
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Janice Connell
- ScHARR, University of Sheffield, Sheffield, United Kingdom
| | - Margaret Heslin
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Christopher Foley
- Department of Public Health & Primary Care, Cambridge University, Cambridge, United Kingdom
| | - Faye Plummer
- Bradford Institute for Health Research, Bradford, United Kingdom
| | - Christopher Roberts
- Centre for Biostatistics, University of Manchester, Manchester, United Kingdom
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Gellatly J, Bower P, McMillan D, Roberts C, Byford S, Bee P, Gilbody S, Arundel C, Hardy G, Barkham M, Reynolds S, Gega L, Mottram P, Lidbetter N, Pedley R, Peckham E, Connell J, Molle J, O’Leary N, Lovell K. Obsessive Compulsive Treatment Efficacy Trial (OCTET) comparing the clinical and cost effectiveness of self-managed therapies: study protocol for a randomised controlled trial. Trials 2014; 15:278. [PMID: 25011730 PMCID: PMC4226946 DOI: 10.1186/1745-6215-15-278] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 07/01/2014] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND UK National Institute of Health and Clinical Excellence guidelines for obsessive compulsive disorder (OCD) specify recommendations for the treatment and management of OCD using a stepped care approach. Steps three to six of this model recommend treatment options for people with OCD that range from low-intensity guided self-help (GSH) to more intensive psychological and pharmacological interventions. Cognitive behavioural therapy (CBT), including exposure and response prevention, is the recommended psychological treatment. However, whilst there is some preliminary evidence that self-managed therapy packages for OCD can be effective, a more robust evidence base of their clinical and cost effectiveness and acceptability is required. METHODS/DESIGN Our proposed study will test two different self-help treatments for OCD: 1) computerised CBT (cCBT) using OCFighter, an internet-delivered OCD treatment package; and 2) GSH using a book. Both treatments will be accompanied by email or telephone support from a mental health professional. We will evaluate the effectiveness, cost and patient and health professional acceptability of the treatments. DISCUSSION This study will provide more robust evidence of efficacy, cost effectiveness and acceptability of self-help treatments for OCD. If cCBT and/or GSH prove effective, it will provide additional, more accessible treatment options for people with OCD. TRIAL REGISTRATION Current Controlled Trials: ISRCTN73535163. Date of registration: 5 April 2011.
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Affiliation(s)
- Judith Gellatly
- School of Nursing, Midwifery & Social Work, The University of Manchester, Manchester, UK
| | - Peter Bower
- Centre for Primary Care, The University of Manchester, Manchester, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK
| | - Christopher Roberts
- School of Epidemiology and Health Sciences, The University of Manchester, Manchester, UK
| | - Sarah Byford
- Department of Health Sciences, University of York, York, UK
| | - Penny Bee
- School of Nursing, Midwifery & Social Work, The University of Manchester, Manchester, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | | | - Gillian Hardy
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Michael Barkham
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Shirley Reynolds
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Lina Gega
- Insight Healthcare, Newcastle Upon Tyne, UK
| | - Patricia Mottram
- Cheshire and Wirral Partnership NHS Foundation Trust, Wallasey, UK
| | | | - Rebecca Pedley
- School of Nursing, Midwifery & Social Work, The University of Manchester, Manchester, UK
| | - Emily Peckham
- Department of Health Sciences, University of York, York, UK
| | | | - Jo Molle
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Neil O’Leary
- School of Epidemiology and Health Sciences, The University of Manchester, Manchester, UK
| | - Karina Lovell
- School of Nursing, Midwifery & Social Work, The University of Manchester, Manchester, UK
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Gega L, Swift L, Barton G, Todd G, Reeve N, Bird K, Holland R, Howe A, Wilson J, Molle J. Computerised therapy for depression with clinician vs. assistant and brief vs. extended phone support: study protocol for a randomised controlled trial. Trials 2012; 13:151. [PMID: 22925596 PMCID: PMC3495903 DOI: 10.1186/1745-6215-13-151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 07/31/2012] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Computerised cognitive behaviour therapy (cCBT) involves standardised, automated, interactive self-help programmes delivered via a computer. Randomised controlled trials (RCTs) and observational studies have shown than cCBT reduces depressive symptoms as much as face-to-face therapy and more than waiting lists or treatment as usual. cCBT's efficacy and acceptability may be influenced by the "human" support offered as an adjunct to it, which can vary in duration and can be offered by people with different levels of training and expertise. METHODS/DESIGN This is a two-by-two factorial RCT investigating the effectiveness, cost-effectiveness and acceptability of cCBT supplemented with 12 weekly phone support sessions are either brief (5-10 min) or extended (20-30 min) and are offered by either an expert clinician or an assistant with no clinical training. Adults with non-suicidal depression in primary care can self-refer into the study by completing and posting to the research team a standardised questionnaire. Following an assessment interview, eligible referrals have access to an 8-session cCBT programme called Beating the Blues and are randomised to one of four types of support: brief-assistant, extended-assistant, brief-clinician or extended-clinician.A sample size of 35 per group (total 140) is sufficient to detect a moderate effect size with 90% power on our primary outcome measure (Work and Social Adjustment Scale); assuming a 30% attrition rate, 200 patients will be randomised. Secondary outcome measures include the Beck Depression and Anxiety Inventories and the PHQ-9 and GAD-7. Data on clinical outcomes, treatment usage and patient experiences are collected in three ways: by post via self-report questionnaires at week 0 (randomisation) and at weeks 12 and 24 post-randomisation; electronically by the cCBT system every time patients log-in; by phone during assessments, support sessions and exit interviews. DISCUSSION The study's factorial design increases its efficiency by allowing the concurrent investigation of two types of adjunct support for cCBT with a single sample of participants. Difficulties in recruitment, uptake and retention of participants are anticipated because of the nature of the targeted clinical problem (depression impairs motivation) and of the studied interventions (lack of face-to-face contact because referrals, assessments, interventions and data collection are completed by phone, computer or post). TRIAL REGISTRATION Current Controlled Trials ISRCTN98677176.
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Affiliation(s)
- Lina Gega
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Louise Swift
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Garry Barton
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Gillian Todd
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Norfolk & Suffolk NHS Foundation Trust (NSFT), Hellesdon Hospital, Norwich NR6 5BE, UK
| | - Nesta Reeve
- Norfolk & Suffolk NHS Foundation Trust (NSFT), Hellesdon Hospital, Norwich NR6 5BE, UK
| | - Kelly Bird
- Norfolk & Suffolk NHS Foundation Trust (NSFT), Hellesdon Hospital, Norwich NR6 5BE, UK
| | - Richard Holland
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Amanda Howe
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- NHS Norfolk, Lakeside 400, Old Chapel Way, Broadland Business Park, Norwich NR7 OWG, UK
| | - Jon Wilson
- Norfolk & Suffolk NHS Foundation Trust (NSFT), Hellesdon Hospital, Norwich NR6 5BE, UK
| | - Jo Molle
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Norfolk & Suffolk NHS Foundation Trust (NSFT), Hellesdon Hospital, Norwich NR6 5BE, UK
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Molle J. Reviewing medical documents online when the information is not available in the medical record. J AHIMA 1997; 68:68-9. [PMID: 10166979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- J Molle
- Medical Center Information Technology Department, University of Michingan Medical Center, Ann Arbor, USA
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