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Parry-Jones AR, Stocking K, MacLeod MJ, Clarke B, Werring DJ, Muir KW, Vail A. Phase II randomised, placebo-controlled, clinical trial of interleukin-1 receptor antagonist in intracerebral haemorrhage: BLOcking the Cytokine IL-1 in ICH (BLOC-ICH). Eur Stroke J 2023; 8:819-827. [PMID: 37452707 PMCID: PMC10472954 DOI: 10.1177/23969873231185208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
PURPOSE Recombinant human interleukin-1 receptor antagonist (anakinra) is an anti-inflammatory with efficacy in animal models of stroke. We tested the effect of anakinra on perihaematomal oedema in acute intracerebral haemorrhage (ICH) and explored effects on inflammatory markers. METHODS We conducted a multicentre, randomised, double-blind, placebo-controlled trial in patients with acute, spontaneous, supratentorial ICH between May 2019 and February 2021. Patients were randomised to 100 mg subcutaneous anakinra within 8 h of onset, followed by five, 12-hourly, 100 mg subcutaneous injections, or matched placebo. Primary outcome was oedema extension distance (OED) on a 72 h CT scan. Secondary outcomes included plasma C-reactive protein (CRP) and interleukin-6 (IL-6). FINDINGS 25 patients (target = 80) were recruited, 14 randomised to anakinra, 11 to placebo. Mean age was 67 and 52% were male. The anakinra group had higher median baseline ICH volume (12.6 ml, interquartile range[IQR]:4.8-17.9) versus placebo (5.5 ml, IQR:2.1-10.9). Adjusting for baseline, 72 h OED was not significantly different between groups (mean difference OED anakinra vs placebo -0.05 cm, 95% confidence interval [CI]: -0.17-0.06, p = 0.336). There was no significant difference in area-under-the-curve to Day 4 for IL-6 and CRP, but a post-hoc analysis demonstrated IL-6 was 56% (95% CI: 2%-80%) lower at Day 2 with anakinra. There were 10 and 2 serious adverse events in anakinra and placebo groups, respectively, none attributed to anakinra. CONCLUSION We describe feasibility for delivering anakinra in acute ICH and provide preliminary safety data. We lacked power to test for effects on oedema thus further trials will be required.
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Affiliation(s)
- Adrian R Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Katie Stocking
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mary Joan MacLeod
- The Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Brian Clarke
- Department of Stroke Medicine, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Keith W Muir
- School of Psychology and Neuroscience, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Andy Vail
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Quinn TJ, Taylor-Rowan M, Elliott E, Drozdowska B, McMahon D, Broomfield NM, Barber M, MacLeod MJ, Cvoro V, Byrne A, Ross S, Crow J, Slade P, Dawson J, Langhorne P. Research protocol - Assessing Post-Stroke Psychology Longitudinal Evaluation (APPLE) study: A prospective cohort study in stroke. Cereb Circ Cogn Behav 2022; 3:100042. [PMID: 36324404 PMCID: PMC9616226 DOI: 10.1016/j.cccb.2022.100042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/30/2021] [Accepted: 01/21/2022] [Indexed: 05/26/2023]
Abstract
BACKGROUND Cognitive and mood problems have been highlighted as priorities in stroke research and guidelines recommend early screening. However, there is limited detail on the preferred approach.We aimed to (1) determine the optimal methods for evaluating psychological problems that pre-date stroke; (2) assess the test accuracy, feasibility and acceptability of brief cognitive and mood tests used at various time-points following stroke; (3) describe temporal changes in cognition and mood following stroke and explore predictors of change. METHODS We established a multi-centre, prospective, observational cohort with acute stroke as the inception point - Assessing Post-stroke Psychology Longitudinal Evaluation (APPLE). We approached patients admitted with stroke or transient ischaemic attack (TIA) from 11 different hospital sites across the United Kingdom. Baseline demographics, clinical, functional, cognitive, and mood data were collected. Consenting stroke survivors were followed up with more extensive evaluations of cognition and mood at 1, 6, 12 and 18 months. RESULTS Continuous recruitment was from February 2017 to February 2019. With 357 consented to full follow-up. Eighteen-month assessments were completed in September 2020 with permissions in-place for longer term in-person or electronic follow-up. A qualitative study has been completed, and a participant sample biobank and individual participant database are both available. DISCUSSION The APPLE study will provide guidance on optimal tool selection for cognitive and mood assessment both before and after stroke, as well as information on prognosis and natural history of neuropsychological problems in stroke. The study data, neuroimaging and tissue biobank are all available as a resource for future research.
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Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Emma Elliott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Bogna Drozdowska
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - David McMahon
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Niall M Broomfield
- Department Clinical Psychology and Psychological Therapies, University of East Anglia, United Kingdom
| | - Mark Barber
- Stroke Unit, University Hospital Monklands, United Kingdom
| | - Mary Joan MacLeod
- Department of Medicine and Therapeutics, University of Aberdeen, United Kingdom
| | - Vera Cvoro
- Stroke Unit, Victoria Hospital, Kirkcaldy, United Kingdom
| | - Anthony Byrne
- Department of Ageing & Health, Forth Valley Royal Hospital, Larbert, United Kingdom
| | - Sarah Ross
- Stroke Unit, Perth Royal Infirmary, Perth, United Kingdom
| | - Jennifer Crow
- Imperial College Healthcare NHS Trust, United Kingdom
| | | | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
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Findlay M, MacIsaac R, MacLeod MJ, Metcalfe W, Sood MM, Traynor JP, Dawson J, Mark PB. The Association of Atrial Fibrillation and Ischemic Stroke in Patients on Hemodialysis: A Competing Risk Analysis. Can J Kidney Health Dis 2019; 6:2054358119878719. [PMID: 31632680 PMCID: PMC6767723 DOI: 10.1177/2054358119878719] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/02/2019] [Indexed: 12/16/2022] Open
Abstract
Background Stroke is common in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) and associated with high mortality rate. In the general population, atrial fibrillation (AF) is a major risk factor for stroke and therapeutic anticoagulation is associated with risk reduction, whereas in ESRD the relationship is less clear. Objective The purpose of this study is to demonstrate the influence of AF on stroke rates and probability in those on HD following competing risk analyses. Design A national record linkage cohort study. Setting All renal and stroke units in Scotland, UK. Patients All patients with ESRD receiving HD within Scotland from 2005 to 2013 (follow-up to 2015). Measurements Demographic, clinical, and laboratory data were linked between the Scottish Renal Registry, Scottish Stroke Care Audit, and hospital discharge data. Stroke was defined as a fatal or nonfatal event and mortality derived from national records. Methods Associations for stroke were determined using competing risk models: the cause-specific hazards model and the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of all stroke, ischemic stroke, and first-ever stroke. Results Of 5502 patients treated with HD with 12 348.6-year follow-up, 363 (6.6%) experienced stroke. The stroke incidence rate was 26.7 per 1000 patient-years. Multivariable regression on the cause-specific hazard for stroke demonstrated age, hazard ratio (HR) (95% confidence interval [CI]) = 1.04 (1.03-1.05); AF, HR (95% CI) = 1.88 (1.25-2.83); prior stroke, HR (95% CI) = 2.29 (1.48-3.54), and diabetes, HR (95% CI) = 1.92 (1.45-2.53); serum phosphate, HR (95% CI) = 2.15 (1.56-2.99); lower body weight, HR (95% CI) = 0.99 (0.98-1.00); lower hemoglobin, HR (95% CI) = 0.88 (0.77-0.99); and systolic blood pressure (BP), HR (95% CI) = 1.01 (1.00-1.02), to be associated with an increased stroke rate. In contrast, the subdistribution HRs obtained following Fine and Gray regression demonstrated that AF, weight, and hemoglobin were not associated with stroke risk. In both models, AF was significantly associated with nonstroke death. Limitations Our analyses derive from retrospective data sets and thus can only describe association not causation. Data on anticoagulant use are not available. Conclusions The incidence of stroke in HD patients is high. The competing risk of "prestroke" mortality affects the relationship between AF and risk of future stroke. Trial designs for interventions to reduce stroke risk in HD patients, such as anticoagulation for AF, should take account of competing risks affecting associations between risk factors and outcomes.
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Affiliation(s)
- Mark Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, UK.,On Behalf of the Scottish Stroke Care Audit, Information Services Division, Edinburgh, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, UK.,On Behalf of the Scottish Renal Registry, Information Services Division, Glasgow, UK
| | - Manish M Sood
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
| | - Jamie P Traynor
- The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK.,On Behalf of the Scottish Renal Registry, Information Services Division, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK
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Findlay M, MacIsaac R, MacLeod MJ, Metcalfe W, Traynor JP, Dawson J, Mark PB. Renal replacement modality and stroke risk in end-stage renal disease-a national registry study. Nephrol Dial Transplant 2019; 33:1564-1571. [PMID: 29069522 DOI: 10.1093/ndt/gfx291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/06/2017] [Indexed: 11/12/2022] Open
Abstract
Background The risk of stroke in end-stage renal disease (ESRD) on renal replacement therapy (RRT) is up to 10-fold greater than the general population. However, whether this increased risk differs by RRT modality is unclear. Methods We used data contained in the Scottish Renal Registry and the Scottish Stroke Care Audit to identify stroke in all adult patients who commenced RRT for ESRD from 2005 to 2013. Incidence rate was calculated and regression analyses were performed to identify variables associated with stroke. We explored the effect of RRT modality at initiation and cumulative dialysis exposure by time-dependent regression analysis, using transplant recipients as the reference group. Results A total of 4957 patients commenced RRT for ESRD. Median age was 64.5 years, 41.5% were female and 277 patients suffered a stroke (incidence rate was 18.6/1000 patient-years). Patients who had stroke were older, had higher blood pressure and were more likely to be female and have diabetes. On multivariable regression older age, female sex, diabetes and higher serum phosphate were associated with risk of stroke. RRT modality at initiation was not. On time-dependent analysis, haemodialysis (HD) exposure was independently associated with increased risk of stroke. Conclusions In patients with ESRD who initiate RRT, HD use independently increases risk of stroke compared with transplantation. Use of peritoneal dialysis did not increase risk on adjusted analysis.
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Affiliation(s)
- Mark Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK.,Scottish Stroke Care Audit, ISD, Edinburgh, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Renal Registry, ISD, Glasgow, UK
| | - Jamie P Traynor
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK.,Scottish Renal Registry, ISD, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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5
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Ross J, Broche L, MacLeod MJ, Davies G, Lurie D. [OA020] Fast field-cycling MRI: Novel contrast changes through switched magnetic fields. Phys Med 2018. [DOI: 10.1016/j.ejmp.2018.06.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Langhorne P, O'Donnell MJ, Chin SL, Zhang H, Xavier D, Avezum A, Mathur N, Turner M, MacLeod MJ, Lopez-Jaramillo P, Damasceno A, Hankey GJ, Dans AL, Elsayed A, Mondo C, Wasay M, Czlonkowska A, Weimar C, Yusufali AH, Hussain FA, Lisheng L, Diener HC, Ryglewicz D, Pogosova N, Iqbal R, Diaz R, Yusoff K, Oguz A, Wang X, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Magazi D, Nilanont Y, Rosengren A, Oveisgharan S, Yusuf S. Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study. Lancet 2018; 391:2019-2027. [PMID: 29864018 DOI: 10.1016/s0140-6736(18)30802-x] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/07/2018] [Accepted: 03/21/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels. METHODS We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month. FINDINGS We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14-1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12-1·72) irrespective of other patient and service characteristics. INTERPRETATION Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes. FUNDING Chest, Heart and Stroke Scotland.
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Affiliation(s)
- Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
| | - Martin J O'Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Denis Xavier
- St John's Medical College and Research Institute, Bangalore, India
| | - Alvaro Avezum
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Nandini Mathur
- St John's Medical College and Research Institute, Bangalore, India
| | - Melanie Turner
- Division of Applied Medicine, University of Aberdeen, Aberdeen, UK
| | | | - Patricio Lopez-Jaramillo
- Instituto de Investigaciones FOSCAL, Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | | | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Antonio L Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | | | - Charles Mondo
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | - Mohammad Wasay
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | - Liu Lisheng
- National Center of Cardiovascular Disease, Beijing, China
| | | | | | - Nana Pogosova
- National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Romana Iqbal
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | | | - Aytekin Oguz
- Istanbul Medeniyet Üniversitesi, Istanbul, Turkey
| | - Xingyu Wang
- Beijing Hypertension League Institute, Beijing, China
| | | | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Okechukwu S Ogah
- Division of Cardiovascular Medicine, University College Hospital, Ibadan, Nigeria
| | - Adesola Ogunniyi
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Helle K Iversen
- Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Annika Rosengren
- Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
| | | | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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Findlay MD, Dawson J, MacIsaac R, Jardine AG, MacLeod MJ, Metcalfe W, Traynor JP, Mark PB. Inequality in Care and Differences in Outcome Following Stroke in People With ESRD. Kidney Int Rep 2018; 3:1064-1076. [PMID: 30197973 PMCID: PMC6127409 DOI: 10.1016/j.ekir.2018.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 02/21/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 11/27/2022] Open
Abstract
Introduction Stroke rate and mortality are greater in individuals with end-stage renal disease (ESRD) than in those without ESRD. We examined discrepancies in stroke care in ESRD patients and their influence on mortality. Methods This is a national record linkage cohort study of hospitalized stroke individuals from 2005 to 2013. Presentation, measures of care quality (admission to stroke unit, swallow assessment, antithrombotics, or thrombolysis use), and outcomes were compared in those with and without ESRD after propensity score matching (PSM). We examined the effect of being admitted to a stroke unit on survival using Kaplan-Meier and Cox survival analyses. Results A total of 8757 individuals with ESRD and 61,367 individuals with stroke were identified. ESRD patients (n =486) experienced stroke over 34,551.9 patient-years of follow-up; incidence rates were 25.3 (dialysis) and 4.5 (kidney transplant)/1000 patient-years. After PSM, dialysis patients were less likely to be functionally independent (61.4% vs. 77.7%; P < 0.0001) before stroke, less frequently admitted to stroke units (64.6% vs. 79.6%; P < 0.001), or to receive aspirin (75.3% vs. 83.2%; P = 0.01) than non-ESRD stroke patients. There were no significant differences in management of kidney transplantation patients. Stroke with ESRD was associated with a higher death rate during admission (dialysis 22.9% vs.14.4%, P = 0.002; transplantation: 19.6% vs. 9.3%; P = 0.034). Managing ESRD patients in a stroke unit was associated with a lower risk of death at follow-up (hazard ratio: 0.68; 95% confidence interval: 0.55-0.84). Conclusion Stroke incidence is high in ESRD. Individuals on dialysis are functionally more dependent before stroke and less frequently receive optimal stroke care. After a stroke, death is more likely in ESRD patients. Acute stroke unit care may be associated with lower mortality.
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Affiliation(s)
- Mark D Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jamie P Traynor
- The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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Findlay M, MacLeod MJ, Metcalfe W, Traynor J, Dawson J, Mark P. SP726INCIDENCE, RISK FACTORS AND OUTCOMES OF STROKE IN SCOTLAND'S RENAL TRANSPLANT RECIPIENTS. Nephrol Dial Transplant 2017. [DOI: 10.1093/ndt/gfx157.sp726] [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: 11/14/2022] Open
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Reid JM, Dai D, Delmonte S, Counsell C, Phillips SJ, MacLeod MJ. Simple prediction scores predict good and devastating outcomes after stroke more accurately than physicians. Age Ageing 2017; 46:421-426. [PMID: 27810853 DOI: 10.1093/ageing/afw197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/22/2016] [Indexed: 11/12/2022] Open
Abstract
Introduction physicians are often asked to prognosticate soon after a patient presents with stroke. This study aimed to compare two outcome prediction scores (Five Simple Variables [FSV] score and the PLAN [Preadmission comorbidities, Level of consciousness, Age, and focal Neurologic deficit]) with informal prediction by physicians. Methods demographic and clinical variables were prospectively collected from consecutive patients hospitalised with acute ischaemic or haemorrhagic stroke (2012-13). In-person or telephone follow-up at 6 months established vital and functional status (modified Rankin score [mRS]). Area under the receiver operating curves (AUC) was used to establish prediction score performance. Results five hundred and seventy-five patients were included; 46% female, median age 76 years, 88% ischaemic stroke. Six months after stroke, 47% of patients had a good outcome (alive and independent, mRS 0-2) and 26% a devastating outcome (dead or severely dependent, mRS 5-6). The FSV and PLAN scores were superior to physician prediction (AUCs of 0.823-0.863 versus 0.773-0.805, P < 0.0001) for good and devastating outcomes. The FSV score was superior to the PLAN score for predicting good outcomes and vice versa for devastating outcomes (P < 0.001). Outcome prediction was more accurate for those with later presentations (>24 hours from onset). Conclusion the FSV and PLAN scores are validated in this population for outcome prediction after both ischaemic and haemorrhagic stroke. The FSV score is the least complex of all developed scores and can assist outcome prediction by physicians.
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Affiliation(s)
| | - Dingwei Dai
- Department of Informatics, Independence Blue Cross, Philadelphia, PA, USA
| | | | - Carl Counsell
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Stephen J Phillips
- Dalhousie University Department of Medicine, and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
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Maxwell AE, MacLeod MJ, Joyson A, Johnson S, Ramadan H, Bellfield R, Byrne A, McGhee C, Rudd A, Price F, Vasileiadis E, Holden M, Hewitt J, Carpenter M, Needle A, Valentine S, Patel F, Harrington F, Mudd P, Emsley H, Gregary B, Kane I, Muir K, Tiwari D, Owusu-Agyei P, Temple N, Sekaran L, Ragab S, England T, Hedstrom A, Jones P, Jones S, Doherty M, McCarron MO, Cohen DL, Tysoe S, Al-Shahi Salman R. Reasons for non-recruitment of eligible patients to a randomised controlled trial of secondary prevention after intracerebral haemorrhage: observational study. Trials 2017; 18:162. [PMID: 28381307 PMCID: PMC5382439 DOI: 10.1186/s13063-017-1909-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 10/04/2016] [Accepted: 03/18/2017] [Indexed: 11/19/2022] Open
Abstract
Background Recruitment to randomised prevention trials is challenging, not least for intracerebral haemorrhage (ICH) associated with antithrombotic drug use. We investigated reasons for not recruiting apparently eligible patients at hospital sites that keep screening logs in the ongoing REstart or STop Antithrombotics Randomised Trial (RESTART), which seeks to determine whether to start antiplatelet drugs after ICH. Method By the end of May 2015, 158 participants had been recruited at 108 active sites in RESTART. The trial coordinating centre invited all sites that kept screening logs to submit screening log data, followed by one reminder. We checked the integrity of data, focused on the completeness of data about potentially eligible patients and categorised the reasons they were not randomised. Results Of 108 active sites, 39 (36%) provided usable screening log data over a median of ten (interquartile range = 5–13) months of recruitment per site. During this time, sites screened 633 potentially eligible patients and randomised 53 (8%) of them. The main reasons why 580 patients were not randomised were: 43 (7%) patients started anticoagulation, 51 (9%) patients declined, 148 (26%) patients’ stroke physicians were not uncertain about using antiplatelet drugs, 162 (28%) patients were too unwell and 176 (30%) patients were not randomised due to other reasons. Conclusion RESTART recruited ~8% of eligible patients. If more physicians were uncertain about the therapeutic dilemma that RESTART is addressing, RESTART could have recruited up to four times as many participants. The trial coordinating centre continues to engage with physicians about their uncertainty. Trial registration EU Clinical Trials, EudraCT 2012-003190-26. Registered on 3 July 2012.
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Affiliation(s)
- Amy E Maxwell
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
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- Royal Devon & Exeter Hospital, Exeter, UK
| | | | | | | | - Keith Muir
- South Glasgow University Hospital, Glasgow, UK
| | | | | | | | | | | | | | | | | | | | - Mandy Doherty
- South West Acute Hospital, Enniskillen, UK.,Altnagelvin Hospital, Londonderry, UK
| | | | | | - Sharon Tysoe
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
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Khor MX, Bown A, Barrett A, Counsell CE, MacLeod MJ, Reid JM. Pre-hospital notification is associated with improved stroke thrombolysis timing. J R Coll Physicians Edinb 2016; 45:190-5. [PMID: 26517096 DOI: 10.4997/jrcpe.2015.303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Intravenous thrombolysis increases disability-free survival after acute ischaemic stroke in a time-dependent fashion. We aimed to determine whether pre-hospital notification, introduction of a CT scanner near to assessment site and introduction of out-of-hours thrombolysis services affect thrombolysis timing. Methods Timings related to thrombolysis were collected between May 2012 and June 2014 at a single hospital site; these included time to stroke physician assessment, time to cranial CT imaging and door to needle time. All thrombolysed ischaemic stroke patients admitted via the emergency department were included. Ambulance services were asked to pre-notify the emergency department of any suspected stroke patient during this period. Results We studied 182 patients (48% female; mean age 74 years; 59% pre-notified). Pre-hospital notification was associated with a significantly higher rate of CT scanning within 25 minutes (60% vs 24%, odds ratio [OR] 4.7, 95% confidence interval [CI] 2.4-9.0; p<0.001), earlier stroke physician assessment (median 6 vs 32 minutes; p<0.001) and receiving thrombolysis within 60 minutes (89% vs 49%, OR 8.0, 95% CI 3.8-16.9; p<0.001). Being treated outside normal working hours did not alter thrombolysis timing. Logistic regression identified the introduction of a near-site CT scanner (OR 4.6 [95% CI 1.7-12.5]) and pre-hospital notification (OR 4.7, [95% CI 2.3-9.6]) as independent predictors of door to CT time less than or equal to 25 minutes, and pre-hospital notification (OR 11.6, [95% CI 4.9-30.3]) and stroke severity (OR 1.15 per point of NIHSS scale, [95% CI 1.08-1.23]) as predictors of door to thrombolysis time less than or equal to 60 minutes. The most common perceived timing delays were radiology-related (33%), the need to acutely lower blood pressure (15%) and obtaining consent (12%). Conclusion Pre-hospital notification is associated with earlier stroke physician review, CT imaging and delivery of thrombolysis. Referral to an out of hours thrombolysis service was not associated with additional delay.
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Affiliation(s)
- M X Khor
- MX Khor, Acute Stroke Unit, Ward 204, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK. Email
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12
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Abstract
Background: We aimed to study the timing of aspirin prescription in ischaemic stroke comparing patients admitted to an acute stroke unit (ASU) directly or via a general medical ward. We also analysed prescription of secondary preventive therapies in stroke patients in an ASU. Methods: Retrospective analysis was made of medical notes and prescription records of 69 patients admitted to an ASU over a three month period to establish timing of aspirin prescription with respect to onset of stroke symptoms, CT brain scan and route of admission to the ASU. Results: CT brain scans were obtained at a median of 2.1 days post stroke (IQ range 1.3–4.3). Patients directly admitted to the ASU received aspirin earlier post admission compared to those admitted via a medical ward (0.7 vs 2.2 days, p<0.01) and were also more likely to receive aspirin prior to CT scan being performed (57% vs 19%, p=0.02). 86% of stroke patients were discharged on an antiplatelet therapy, 79% on a statin, 37% on a thiazide diuretic and 32% on an ACE inhibitor or angiotensin II antagonist. Conclusion: Aspirin was given more promptly in acute stroke and more commonly prior to CT scanning in an ASU compared to a medical ward. Statin therapy is used extensively in stroke but there is a much lower rate of initiation of other secondary preventive therapies (e.g. anti-hypertensive therapy) in hospital. These findings demonstrate a hesitancy in early use of aspirin amongst general physicians and lends support for the use of stroke units.
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Affiliation(s)
- J Reid
- Aberdeen Royal Infirmary, Foresterhill, Aberdeen.
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13
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Watson-Fargie T, Dai D, MacLeod MJ, Reid JM. Comparison of predictive scores of symptomatic intracerebral haemorrhage after stroke thrombolysis in a single centre. J R Coll Physicians Edinb 2016; 45:127-32. [PMID: 26181528 DOI: 10.4997/jrcpe.2015.208] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
UNLABELLED Symptomatic intracerebral haemorrhage following thrombolysis for ischaemic stroke causes significant morbidity and mortality. This study assessed which of four risk scores (SEDAN, HAT, GRASPS and SITS) best predicts symptomatic intracerebral haemorrhage. METHODS Data from 431 patients treated at Aberdeen Royal Infirmary (2003-2013) were extracted from a thrombolysis database. Score performance was compared using area under the curve. RESULTS Any intracerebral haemorrhage occurred in 12% of patients (53/413); 11% fulfilling the SITS-MOST symptomatic intracerebral haemorrhage definition (6/53), 34% the ECASS II definition (18/53), and 43% the National Institute of Neurological Disorder and Stroke definition (23/53). Stroke severity, as defined by the National Institutes of Health Stroke Scale, significantly improved after 24 hours in patients without intracerebral haemorrhage, but not in those with. Significant symptomatic intracerebral haemorrhage predictors were age, glucose, stroke severity, hyperdense middle cerebral artery on CT scan, ASPECTS score and anti-platelet therapy. The haemorrhage after thrombolysis score performed best at predicting symptomatic intracerebral haemorrhage (area under the curve 0.67-0.78, p < 0.001). CONCLUSION The haemorrhage after thrombolysis score uses the least variables and has the best predictive value for symptomatic intracerebral haemorrhage. Using predictive scores for clinical decision making depends on estimation of overall benefits as well as risk.
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Affiliation(s)
- T Watson-Fargie
- T Watson-Fargie, Department of Neurosciences, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK. Email
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Varsou O, Stringer MS, Fernandes CD, Schwarzbauer C, MacLeod MJ. Stroke recovery and lesion reduction following acute isolated bilateral ischaemic pontine infarction: a case report. BMC Res Notes 2014; 7:728. [PMID: 25322939 PMCID: PMC4203895 DOI: 10.1186/1756-0500-7-728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 10/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although pontine strokes account for a small percentage of all ischaemic events, they can be associated with significant initial disability. These lesions may be missed on computed tomography and therefore magnetic resonance imaging is generally preferred for the assessment of brainstem strokes. The aetiopathogenesis of isolated pontine infarcts, not due to a significant compromise (occlusion or dissection) in the vertebrobasilar territory, still remains to be fully characterised. These strokes present with different symptoms, depending on the lesion location and size, partly reflecting the anatomical variability of the vertebrobasilar vessels. Progressive neurological deterioration is relatively common and has been associated with the extension of such lesions. However, many patients with significant infarcts in the pons will do well in the future and initial diffusion-weighted imaging may not add useful prognostication to the clinical assessment. We discuss here a case where an initially progressive presentation was associated with a marked improvement in both clinical and radiological assessments at 42 days. CASE PRESENTATION A 49-year-old white British man presented with left-sided weakness, incoordination, unsteadiness, cerebellar ataxic dysarthria and dysphonia. A baseline magnetic resonance imaging scan with diffusion-weighted imaging, T1-weighted and T2-weighted sequences showed an acute bilateral pontine infarct. On a repeat scan at 42 days, there was a 57.5% decrease in the size of the lesion on the high-resolution three-dimensional T1-weighted image and a corresponding improvement in the symptoms and the clinical assessments of this patient. The reduction in infarct size was also comparable to the decrease calculated between the baseline diffusion-weighted and the follow-up fluid attenuated inversion recovery sequences. CONCLUSION This case report discusses the significant clinical improvement and corresponding lesion reduction in a patient that presented with worsening neurological symptoms and was diagnosed with acute bilateral ischaemic pontine infarction. Further studies, utilising structural and functional magnetic resonance imaging with follow-up scans, are needed to provide better insights into the underlying aetiopathology and recovery mechanisms of pontine stroke. These will help define the relationship between imaging parameters and outcome allowing for better prognosis along with the development of relevant rehabilitation programs for this group of patients.
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Affiliation(s)
- Ourania Varsou
- Aberdeen Biomedical Imaging Centre, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK.
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16
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Ryan C, Ross S, Davey P, Duncan EM, Fielding S, Francis JJ, Johnston M, Ker J, Lee AJ, MacLeod MJ, Maxwell S, McKay G, McLay J, Webb DJ, Bond C. Junior doctors' perceptions of their self-efficacy in prescribing, their prescribing errors and the possible causes of errors. Br J Clin Pharmacol 2014; 76:980-7. [PMID: 23627415 DOI: 10.1111/bcp.12154] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [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: 08/07/2012] [Accepted: 03/08/2013] [Indexed: 12/01/2022] Open
Abstract
AIMS The aim of the study was to explore and compare junior doctors' perceptions of their self-efficacy in prescribing, their prescribing errors and the possible causes of those errors. METHODS A cross-sectional questionnaire study was distributed to foundation doctors throughout Scotland, based on Bandura's Social Cognitive Theory and Human Error Theory (HET). RESULTS Five hundred and forty-eight questionnaires were completed (35.0% of the national cohort). F1s estimated a higher daytime error rate [median 6.7 (IQR 2-12.4)] than F2s [4.0 IQR (0-10) (P = 0.002)], calculated based on the total number of medicines prescribed. The majority of self-reported errors (250, 49.2%) resulted from unintentional actions. Interruptions and pressure from other staff were commonly cited causes of errors. F1s were more likely to report insufficient prescribing skills as a potential cause of error than F2s (P = 0.002). The prescribers did not believe that the outcomes of their errors were serious. F2s reported higher self-efficacy scores than F1s in most aspects of prescribing (P < 0.001). CONCLUSION Foundation doctors were aware of their prescribing errors, yet were confident in their prescribing skills and apparently complacent about the potential consequences of prescribing errors. Error causation is multi-factorial often due to environmental factors, but with lack of knowledge also contributing. Therefore interventions are needed at all levels, including environmental changes, improving knowledge, providing feedback and changing attitudes towards the role of prescribing as a major influence on patient outcome.
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Affiliation(s)
- Cristín Ryan
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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17
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McVerry F, Dani KA, MacDougall NJ, MacLeod MJ, Wardlaw J, Muir KW. Derivation and Evaluation of Thresholds for Core and Tissue at Risk of Infarction Using CT Perfusion. J Neuroimaging 2014; 24:562-568. [DOI: 10.1111/jon.12134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 02/06/2014] [Accepted: 03/31/2014] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ferghal McVerry
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
| | - Krishna Ashok Dani
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
| | - Niall J.J. MacDougall
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
| | - Mary Joan MacLeod
- Department of Medicine and Therapeutics; University of Aberdeen; United Kingdom
| | - Joanna Wardlaw
- Division of Clinical Neurosciences; Western General Hospital; Edinburgh United Kingdom
| | - Keith W Muir
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
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Ryan C, Ross S, Davey P, Duncan EM, Francis JJ, Fielding S, Johnston M, Ker J, Lee AJ, MacLeod MJ, Maxwell S, McKay GA, McLay JS, Webb DJ, Bond C. Prevalence and causes of prescribing errors: the PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) study. PLoS One 2014; 9:e79802. [PMID: 24404122 PMCID: PMC3880263 DOI: 10.1371/journal.pone.0079802] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 09/25/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Study objectives were to investigate the prevalence and causes of prescribing errors amongst foundation doctors (i.e. junior doctors in their first (F1) or second (F2) year of post-graduate training), describe their knowledge and experience of prescribing errors, and explore their self-efficacy (i.e. confidence) in prescribing. METHOD A three-part mixed-methods design was used, comprising: prospective observational study; semi-structured interviews and cross-sectional survey. All doctors prescribing in eight purposively selected hospitals in Scotland participated. All foundation doctors throughout Scotland participated in the survey. The number of prescribing errors per patient, doctor, ward and hospital, perceived causes of errors and a measure of doctors' self-efficacy were established. RESULTS 4710 patient charts and 44,726 prescribed medicines were reviewed. There were 3364 errors, affecting 1700 (36.1%) charts (overall error rate: 7.5%; F1:7.4%; F2:8.6%; consultants:6.3%). Higher error rates were associated with : teaching hospitals (p<0.001), surgical (p = <0.001) or mixed wards (0.008) rather thanmedical ward, higher patient turnover wards (p<0.001), a greater number of prescribed medicines (p<0.001) and the months December and June (p<0.001). One hundred errors were discussed in 40 interviews. Error causation was multi-factorial; work environment and team factors were particularly noted. Of 548 completed questionnaires (national response rate of 35.4%), 508 (92.7% of respondents) reported errors, most of which (328 (64.6%) did not reach the patient. Pressure from other staff, workload and interruptions were cited as the main causes of errors. Foundation year 2 doctors reported greater confidence than year 1 doctors in deciding the most appropriate medication regimen. CONCLUSIONS Prescribing errors are frequent and of complex causation. Foundation doctors made more errors than other doctors, but undertook the majority of prescribing, making them a key target for intervention. Contributing causes included work environment, team, task, individual and patient factors. Further work is needed to develop and assess interventions that address these.
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Affiliation(s)
- Cristín Ryan
- School of Pharmacy, Queen's University Belfast, Belfast, United Kindgom
| | - Sarah Ross
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | - Peter Davey
- School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Eilidh M. Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Jill J. Francis
- Health Services Research and Management Division, City University London, London, United Kingdom
| | - Shona Fielding
- Medical Statistics Team, University of Aberdeen, Aberdeen, United Kingdom
| | - Marie Johnston
- Health Psychology, University of Aberdeen, Aberdeen, United Kingdom
| | - Jean Ker
- School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Amanda Jane Lee
- Medical Statistics Team, University of Aberdeen, Aberdeen, United Kingdom
| | - Mary Joan MacLeod
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | - Simon Maxwell
- Clinical Pharmacology Unit, University of Edinburgh, Edinburgh, United Kindgom
| | - Gerard A. McKay
- Department of Clinical Pharmacology, Glasgow Royal Infirmary, Glasgow, United Kindgom
| | - James S. McLay
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | - David J. Webb
- Clinical Pharmacology Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, United Kindgom
| | - Christine Bond
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
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19
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Ross S, Ryan C, Duncan EM, Francis JJ, Johnston M, Ker JS, Lee AJ, MacLeod MJ, Maxwell S, McKay G, McLay J, Webb DJ, Bond C. Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programme. BMJ Qual Saf 2012; 22:97-102. [PMID: 23112288 DOI: 10.1136/bmjqs-2012-001175] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Prescribing errors are a major cause of patient safety incidents. Understanding the underlying factors is essential in developing interventions to address this problem. This study aimed to investigate the perceived causes of prescribing errors among foundation (junior) doctors in Scotland. METHODS In eight Scottish hospitals, data on prescribing errors were collected by ward pharmacists over a 14-month period. Foundation doctors responsible for making a prescribing error were interviewed about the perceived causes. Interview transcripts were analysed using content analysis and categorised into themes previously identified under Reason's Model of Accident Causation and Human Error. RESULTS 40 prescribers were interviewed about 100 specific errors. Multiple perceived causes for all types of error were identified and were categorised into five categories of error-producing conditions, (environment, team, individual, task and patient factors). Work environment was identified as an important aspect by all doctors, especially workload and time pressures. Team factors included multiple individuals and teams involved with a patient, poor communication, poor medicines reconciliation and documentation and following incorrect instructions from other members of the team. A further team factor was the assumption that another member of the team would identify any errors made. The most frequently noted individual factors were lack of personal knowledge and experience. The main task factor identified was poor availability of drug information at admission and the most frequently stated patient factor was complexity. CONCLUSIONS This study has emphasised the complex nature of prescribing errors, and the wide range of error-producing conditions within hospitals including the work environment, team, task, individual and patient. Further work is now needed to develop and assess interventions that address these possible causes in order to reduce prescribing error rates.
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Affiliation(s)
- Sarah Ross
- Division of Medical and Dental Education, School of Medicine and Dentistry, University of Aberdeen, Foresterhill, Aberdeen, UK.
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Jacobson EU, Bayer S, MacLeod MJ. Service redesign: Address the barriers and deliver acute stroke care. Health Serv J 2012; 122:28-29. [PMID: 23390724] [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: 06/01/2023]
Affiliation(s)
- Evin Uzun Jacobson
- Imperial College London, Health and Care Infrastructure Research and Innovation Centre
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Sahraie A, Trevethan CT, MacLeod MJ, Murray AD, Olson JA, Weiskrantz L. Increased sensitivity after repeated stimulation of residual spatial channels in blindsight. Proc Natl Acad Sci U S A 2006; 103:14971-6. [PMID: 17000999 PMCID: PMC1595460 DOI: 10.1073/pnas.0607073103] [Citation(s) in RCA: 126] [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: 11/18/2022] Open
Abstract
Lesions of the occipital cortex result in areas of cortical blindness affecting the corresponding regions of the patient's visual field. The traditional view is that, aside from some spontaneous recovery in the first few months after the damage, when acute effects have subsided the areas of blindness are absolute and permanent. It has been found, however, that within such field defects some residual visual capacities may persist in the absence of acknowledged awareness by the subject (blindsight type 1) or impaired awareness (type 2). Neuronal pathways mediating blindsight have a specific and narrow spatial and temporal bandwidth. A group of cortically blind patients (n = 12) carried out a daily detection "training" task over a 3-month period, discriminating grating visual stimuli optimally configured for blindsight from homogeneous luminance-matched stimuli. No feedback was given during the training. Assessment of training was by psychophysical measurements carried out before and after training and included detection of a range of spatial frequencies (0.5-7 cycles per degree), contrast detection at 1 cycle per degree, clinical perimetry, and subjective estimates of visual field defect. The results show that repeated stimulation by appropriate visual stimuli can result in improvements in visual sensitivities in the very depths of the field defect.
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Affiliation(s)
- Arash Sahraie
- *Vision Research Laboratories, School of Psychology, University of Aberdeen, Aberdeen AB24 2UB, United Kingdom
| | - Ceri T. Trevethan
- *Vision Research Laboratories, School of Psychology, University of Aberdeen, Aberdeen AB24 2UB, United Kingdom
| | - Mary Joan MacLeod
- School of Medicine, University of Aberdeen, Aberdeen AB25 2ZD, United Kingdom; and
| | - Alison D. Murray
- School of Medicine, University of Aberdeen, Aberdeen AB25 2ZD, United Kingdom; and
| | - John A. Olson
- School of Medicine, University of Aberdeen, Aberdeen AB25 2ZD, United Kingdom; and
| | - Lawrence Weiskrantz
- *Vision Research Laboratories, School of Psychology, University of Aberdeen, Aberdeen AB24 2UB, United Kingdom
- Department of Experimental Psychology, University of Oxford, South Parks Road, Oxford OX1 3UD, United Kingdom
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Abstract
Despite many years of study, questions remain about why patients do or do not take medicines and what can be done to change their behaviour. Hypertension is poorly controlled in the UK and poor compliance is one possible reason for this. Recent questionnaires based on the self-regulatory model have been successfully used to assess illness perceptions and beliefs about medicines. This study was designed to describe hypertensive patients' beliefs about their illness and medication using the self-regulatory model and investigate whether these beliefs influence compliance with antihypertensive medication. We recruited 514 patients from our secondary care population. These patients were asked to complete a questionnaire that included the Beliefs about Medicines and Illness Perception Questionnaires. A case note review was also undertaken. Analysis shows that patients who believe in the necessity of medication are more likely to be compliant (odds ratio (OR)) 3.06 (95% CI 1.74-5.38), P<0.001). Other important predictive factors in this population are age (OR 4.82 (2.85-8.15), P<0.001), emotional response to illness (OR 0.65 (0.47-0.90), P=0.01) and belief in personal ability to control illness (OR 0.59 (0.40-0.89), P=0.01). Beliefs about illness and about medicines are interconnected; aspects that are not directly related to compliance influence it indirectly. The self-regulatory model is useful in assessing patients health beliefs. Beliefs about specific medications and about hypertension are predictive of compliance. Information about health beliefs is important in achieving concordance and may be a target for intervention to improve compliance.
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Affiliation(s)
- S Ross
- Department of Medicine and Therapeutics, Medical School, University of Aberdeen, Foresterhill, Aberdeen, UK.
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Sahraie A, Trevethan CT, Weiskrantz L, Olson J, MacLeod MJ, Murray AD, Dijkhuizen RS, Counsell C, Coleman R. Spatial channels of visual processing in cortical blindness. Eur J Neurosci 2003; 18:1189-96. [PMID: 12956717 DOI: 10.1046/j.1460-9568.2003.02853.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Blindsight is the ability of some cortically blind patients to discriminate visual events presented within their field defect. We have examined a fundamental aspect of visual processing, namely the detection of spatial structures presented within the field defect of 10 cortically blind patients. The method outlined is based on the detection of high-contrast stimuli and is effective in flagging a 'window of detection' in the spatial frequency spectrum, should it exist. Here we report on the presence of a narrowly tuned psychophysical spatial channel optimally responding to frequencies less than 4 cycles/ degrees in eight out of 10 patients tested. The two patients who did not show any evidence of blindsight appear to have intact midbrain structures, but have lesions that extend from the occipital cortex to the thalamus. In addition, we have recorded subjective reports of awareness of the visual events in each trial. Detection scores of eight blindsight patients were subsequently subdivided based on the subjective reports of awareness. It appears that the psychophysical spatial channel-mediating responses in the absence of any awareness of the visual event have a narrower frequency response than those involved when the patients report some awareness of the visual event. The findings are discussed in relation to previous reports on the incidence of blindsight and performance on tasks involving spatial processing.
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Affiliation(s)
- Arash Sahraie
- Department of Psychology, University of Aberdeen, Aberdeen AB24 2UB, UK.
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24
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MacLeod MJ. The three horsemen: drought, disease, population and the difficulties of 1726-27 in the Guadalajara region. SECOLAS Ann 2001; 9:33-46. [PMID: 11635945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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MacLeod MJ. The "Matlazáhuatl" of 1737-1738 in some villages in the Guadalajara region. Stud Soc Sci West Ga Coll 2001; 25:7-17. [PMID: 11618188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Abstract
BACKGROUND Apolipoprotein E epsilon4 allele has been associated with increased risk of coronary heart disease, and is also a major genetic susceptibility locus for Alzheimer's disease. Some studies have shown an association between apoE genotype and ischaemic stroke or outcome following stroke, while other studies have failed to do so. Materials and methods Using PCR and the Taqman fluorescence system to detect polymorphisms we examined apoE genotype in 266 ischaemic stroke cases and in a control population. RESULTS We found no association between apoeE epsilon 4 allele distribution and ischaemic stroke, or with outcome following stroke as measured using the Rankin score. Conclusion This study disagrees with a recent meta-analysis, and suggests that further studies are required to clarify the exact relationship between apoE genotype and ischaemic stroke.
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MacLeod MJ, Dahiyat MT, Cumming A, Meiklejohn D, Shaw D, St Clair D. No association between Glu/Asp polymorphism of NOS3 gene and ischemic stroke. Neurology 1999; 53:418-20. [PMID: 10430441 DOI: 10.1212/wnl.53.2.418] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Endothelial nitric oxide synthase (NOS3) gene has been shown to modulate the degree of cerebral ischemia following stroke in animal models and is thus a candidate genetic risk factor for stroke. We compared 265 ischemic stroke cases with 293 controls and found no difference in distribution of the common structural variant Glu/Asp in codon 298 of exon 7 in the NOS3 gene. Our data do not support the hypothesis that NOS3 is a genetic risk factor for stroke.
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Affiliation(s)
- M J MacLeod
- Department of Medicine and Therapeutics, University of Aberdeen, Foresterhill, UK
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Abstract
Five patients with severe spinal muscular atrophy (SMA) type I, all of whom presented with reduced fetal movements in utero, severe weakness at birth, and short survival time were assessed to attempt to determine whether their phenotype could be explained by their genotype. The diagnosis was confirmed by clinical, electrophysiological and histopathological features. Polymerase chain reaction assays were used to define the molecular diagnosis. A gene-dosage assay was used to assess the quantity of centromeric survival motor neuron gene (SMNc) present. In all cases the telomeric survival motor neuron gene (SMNt) was absent. The SMNc gene was present but in reduced copy number compared with a control group of children with less severe type I SMA, so may be important in determining severity. In the differential diagnosis of reduced fetal movements, SMA should be considered. The clinical classification may in future be clarified by molecular genetic findings.
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Affiliation(s)
- M J MacLeod
- Department of Paediatric Neurology, Guy's Hospital, St Thomas Street, London, SE1 9RT, UK
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29
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Abstract
Hypertension and diabetes mellitus are both common conditions associated with a high morbidity and mortality. When the two conditions occur together, as they do in 50% of diabetic individuals, the result is a 7.2-fold increase in mortality. If hypertension occurs in association with diabetes mellitus and diabetic nephropathy, mortality rises to 37-fold above that of a healthy population. Despite the increase in incidence of nephropathy, cardiovascular disease remains the major cause of death in diabetic individuals. Therapy should therefore take into consideration the results of large, placebo-controlled trials which have shown reduction in cardiovascular morbidity and mortality as a result of active treatment. Although studies with the newer antihypertensive agents such as calcium antagonists and angiotensin converting enzyme (ACE) inhibitors are ongoing, only diuretics and beta-adrenoceptor antagonists have been clearly shown to reduce cardiovascular risk. Despite concerns regarding adverse metabolic effects and loss of hypoglycaemic awareness, beta-blockers and diuretics do have a role in the management of diabetic patients. While it is clear that ACE inhibitors reduce the progression of diabetic nephropathy, evidence suggests that diuretics may be just as effective. However, unlike diuretics or beta-blockers, ACE inhibitors have no proven benefit in the prevention of stroke of myocardial infarction. Despite the claims of metabolic neutrality made for many antihypertensive agents there appears to be no advantage in their use in the majority of hypertensive diabetic patients, except where there exist specific contraindications to established therapies.
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Affiliation(s)
- M J MacLeod
- Department of Medicine and Therapeutics, University of Aberdeen, Scotland.
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Harden PN, MacLeod MJ, Rodger RS, Baxter GM, Connell JM, Dominiczak AF, Junor BJ, Briggs JD, Moss JG. Effect of renal-artery stenting on progression of renovascular renal failure. Lancet 1997; 349:1133-6. [PMID: 9113012 DOI: 10.1016/s0140-6736(96)10093-3] [Citation(s) in RCA: 320] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Placement of renal-artery stents has a high technical success rate in atherosclerotic renovascular disease, but little is known about the clinical benefits of the procedure. We monitored renal function serially before and after stent insertion in patients with renovascular renal failure. METHODS Renal function was assessed before and after stent placement by means of serial serum creatinine values in 32 patients with atherosclerotic renal-artery stenosis. The effect on the progression of renal failure was analysed in 23 patients by comparison of the reciprocal slopes of serum creatinine versus time plots before and after stent placement. FINDINGS 33 transluminal stents were placed in 32 patients with atherosclerotic renovascular disease. Immediate patency was achieved in all cases: the angiographic restenosis rate at 6 months was 12% (n = 24). One patient died after a procedure-related haemorrhage. Median diastolic blood pressure was significantly lower after stenting than before (95 [IQR 86-103] vs 87 [81-90] mm Hg; p > 0.01) but the requirement for antihypertensive drugs was unchanged. Renal function improved or stabilised in 22 (69%) of the 32 patients. Progression of renal failure was significantly slowed after the procedure; the mean (SE) of the slopes of reciprocal serum creatinine values was -4.34 (0.85) L mumol-1 day-1 before stent placement, and -0.55 (1.0) L mumol-1 day-1 after stent placement (p < 0.01, two-sample t test). INTERPRETATION Renal-stent placement in selected patients slows the progression of renovascular renal failure and may delay the need for renal replacement therapy.
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Affiliation(s)
- P N Harden
- Renal Unit, Western Infirmary, Glasgow, UK
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MacLeod MJ, Lee WK, Devlin AM, Caslake M, Anderson NH, Packard CJ, Dominiczak MH, Reid JL, Dominiczak AF. Sodium-lithium countertransport, sodium-hydrogen exchange and membrane microviscosity in patients with hyperlipidaemia. Clin Sci (Lond) 1997; 92:237-46. [PMID: 9093003 DOI: 10.1042/cs0920237] [Citation(s) in RCA: 3] [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] [Indexed: 02/04/2023]
Abstract
1. We measured sodium-lithium countertransport, sodium-hydrogen exchange and membrane micro-viscosity in 48 individuals with familial hypercholesterolaemia, 33 subjects with hypertriglyceridaemia and 54 normolipaemic controls. Full lipid profile, blood pressure, body mass index, fasting glucose and insulin levels were also measured. 2. Subjects with hypertriglyceridaemia had higher blood pressure, body mass index, fasting glucose and insulin levels than normal controls. 3. Vmax of the sodium-lithium countertransport was elevated in the hypertriglyceridaemic group compared with controls. Across the whole group log(e) triacylglycerols correlated with Vmax of the sodium-lithium countertransport. There was no difference in sodium-lithium countertransport K(m) between the groups. 4. Sodium-hydrogen maximal proton efflux rate (Vmax) and K(m) were not different between the three groups. There were no correlations between sodium-hydrogen exchange and sodium-lithium countertransport parameters. 5. Microviscosity as measured by diphenylhexatriene was reduced at the core of the membrane in subjects with hypertriglyceridaemia compared with those with familial hypercholesterolaemia or normolipaemic controls, suggesting an alteration in membrane structure. 6. Changes in sodium transport in hyperlipidaemia may be mediated by changes in membrane structure resulting in altered protein conformation or turnover.
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Affiliation(s)
- M J MacLeod
- Department of Medicine and Therapeutics, Western Infirmary, Glasgow, U.K
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MacLeod MJ, Connell JM, Harden PN, Briggs JD, Moss J, Dominiczak AF. Transluminal vascular stents for ostial atherosclerotic renal artery stenosis. Lancet 1995; 346:1109-10. [PMID: 7564824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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