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A Machine Learning Framework Integrating Electronic Health Records for Survival Prognostication in Cervix Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e529. [PMID: 37785643 DOI: 10.1016/j.ijrobp.2023.06.1809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Recent advances in Machine learning (ML) have led to promising clinical applications in oncology, such as improved detection on imaging, predicting emergency department visits, and predicting survival. The hypothesis of this study is a machine learning model using features extracted from electronic health records can be created to improve individual prognostication in patients with cervix cancer managed with radiotherapy in a binary higher and lower risk group model. MATERIALS/METHODS This study used a single-institution retrospective dataset. Electronic records of patients treated for cervix cancer with definitive radiotherapy from 2003-2014 were queried. Features were selected for model building were based on relevant clinical variables and ease of abstraction from records: age, race, smoking status, parity, self-reported unintentional weight loss, histology, revised 2018 Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) staging, tumor size, number of enlarged lymph nodes, involved node location, presence of metastases, radiotherapy duration, and concurrent chemotherapy. The dataset was split into training and testing cohorts, with multivariable Cox regression with Lasso regularization performed to predict hazard ratios (HR), and internal 5-fold cross-validation (training set) to determine the regularization parameter. For each patient, a partial HR using all variables was predicted. A cut-off value maximally splitting the training dataset into higher and lower risk cohorts was calculated in the training dataset using Kaplan-Meier estimates and log-rank tests, and this predicted cut-off value was evaluated in the test dataset. RESULTS A total of 226 patients were included in study, with a median follow-up of 55.1 months; 226 patients in training cohort, and 57 in testing cohort. Feature concordance indices of 0.74 and 0.75 were obtained in the testing and training datasets, respectively, with minimal over-fitting. The three variables that contributed most to the model (with Log HR, 95% CI, p-value) were FIGO stage (0.38, 0.1-0.66, p = 0.01), presence of metastases (0.26, -0.02-0.53, p = 0.07), and unintentional weight loss (-0.34, -0.54-0.14, p<0.01), and FIGO IIB maximally divided the cohort into higher and lower risk stage groupings. A partial HR of 1.15 threshold using all features predicted the largest survival separation between higher and lower risk patients, more so than stage alone (p = 1.18 × 10-3 separated by stage alone vs p = 8.97 × 10-7 separated by partial hazard). CONCLUSION A machine learning approach was able to improve prognostication of survival in cervix cancer using additional features from electronic health records. Future work should explore prognostication using large scale datasets and pre-treatment variables for potential incorporation into patient discussions and shared decision making.
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Impacts of Wildfire Events on California Radiation Oncology Clinics and Patients. Int J Radiat Oncol Biol Phys 2023; 117:e597. [PMID: 37785802 DOI: 10.1016/j.ijrobp.2023.06.1955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The impact of climate-related disasters such as wildfires on healthcare delivery and cancer care is a growing concern. Patients undergoing radiotherapy are particularly vulnerable to treatment interruptions which are known to have a direct impact on survival outcomes. We report results of the first pilot study characterizing the impact of wildfires on radiation oncology clinics and their patients. MATERIALS/METHODS A survey was sent to 415 California radiation oncologists representing 144 clinics identified using the ASTRO member directory to gather information about clinic and radiation oncologist demographics, wildfires' impacts on the clinic (physical/operational), physicians, staff, and patients between 2017 and 2022, as well as clinics' disaster preparedness efforts. RESULTS A total of 51 radiation oncologists completed the survey, representing 43 clinics (30% of clinics) in 24 (41%) of California counties. 35 (69%) of respondents self-identified as male, 27 (53%) worked at hospital-affiliated centers, 19 (37%) worked in academic centers, with 49 (96%) practicing in metropolitan areas. A total of 31 clinics were impacted by a wildfire between 2017 and 2020. The two rural clinics (100%) and 29 (59%) of metro practices reported being impacted by wildfires in the last 5 years, with 9 (18%) reporting a clinic closure and 15 (29%) reporting staffing shortages. 28 (55%) of respondents reported impacts on patients including having to evacuate, 27 (53%) having to cancel or reschedule treatments, and 23 (45%) experiencing physical, mental, or financial hardship due to the wildfires. Among the 25 clinics impacted by wildfires, 12 (24%) reported physical/operational impacts including being forced to evacuate patients to another treatment center, transportation interruptions (19, 37%), community and regional evacuations (18, 35%), school closures (18, 35%), and physical/mental health impacts (14, 27%) on staff due to the wildfires. Small clinics (25 staff or less) that experienced a wildfire were twice as likely to experience closures (6 of 16 clinics, 38%) but equally likely to experience staffing shortages (8 of 16, 50 %) as compared to larger practices (7 of 15, 47%). Nearly half of respondents 25 (47%) reported their workplace had a wildfire emergency preparedness plan. CONCLUSION The results of this study demonstrate the significant impact wildfires have on patient care in both rural and metropolitan areas. The findings emphasize the importance of emergency preparedness planning to minimize the consequences of such disasters and underscores the need for further research to explore risk factors associated with patient and community vulnerability to climate-related crises. Such research will be essential to informing and developing future emergency preparedness plans.
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Image-Guided High-Dose-Rate Brachytherapy for Definitive Management of Primary Vaginal Cancer: A Single Institutional Experience. Int J Radiat Oncol Biol Phys 2023; 117:e526. [PMID: 37785636 DOI: 10.1016/j.ijrobp.2023.06.1802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To assess the safety and efficacy of image-guided high-dose-rate brachytherapy (IGBT) alone or in combination with external beam radiation therapy (EBRT) for the treatment of vaginal cancers. MATERIALS/METHODS The study analyzed patients diagnosed with primary vaginal cancers from 2004 to 2021 who received definitive radiotherapy at a single institution. Interstitial implants were performed using a freehand technique and transvaginal or transrectal-ultrasound for imaging guidance. IGBT was planned using inverse planning simulated annealing (IPSA) software. Data collected and analyzed included patient and tumor characteristics, dose and fractionation, and treatment outcomes. Complications were assessed using CTCAEv4 scores, and descriptive and survival analyses were performed using R-studio. RESULTS Sixty-six patients met inclusion criteria. Patients were staged as I (14), II (23), III (19), and IV (10) based on revised FIGO 2018 staging. 47 (72%) had squamous cell carcinoma histology, and median age was 65 years. The most common regimen was 45 Gy in 25 fractions of EBRT followed by IGBT boost of 18 Gy in 3 fractions with 1 implant (n = 40). For melanoma, an IGBT boost of 19 Gy in 2 fractions with a single implant was used (n = 7). For IGBT monotherapy, the most common regimen was 36 Gy in 6 fractions delivered over 2 implants (n = 3). 41 (66%) of the patients received systemic therapy. Local failures occurred in 8 (12%) patients, while 8 (12%) developed distant metastases. Median overall survival was 64.7 months. Overall survival was 64.3% (95% CI 51.9-79.7%) at 3 years, and 50.9% (95% CI 35.7-72.5%) at 5 years. Grade 3 or 4 toxicities were reported in 4 (6%) patients including vaginal fistula (n = 3) and urethral stricture (n = 1). CONCLUSION The results suggest that utilizing IGBT for freehand interstitial implants in combination with EBRT is a safe and effective primary treatment for vaginal cancer, with durable local control and low toxicity. Further research is needed to establish multi-institutional practice patterns and recommendations.
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Induction of lysosomal and mitochondrial biogenesis by AMPK phosphorylation of FNIP1. Science 2023; 380:eabj5559. [PMID: 37079666 PMCID: PMC10794112 DOI: 10.1126/science.abj5559] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 03/22/2023] [Indexed: 04/22/2023]
Abstract
Cells respond to mitochondrial poisons with rapid activation of the adenosine monophosphate-activated protein kinase (AMPK), causing acute metabolic changes through phosphorylation and prolonged adaptation of metabolism through transcriptional effects. Transcription factor EB (TFEB) is a major effector of AMPK that increases expression of lysosome genes in response to energetic stress, but how AMPK activates TFEB remains unresolved. We demonstrate that AMPK directly phosphorylates five conserved serine residues in folliculin-interacting protein 1 (FNIP1), suppressing the function of the folliculin (FLCN)-FNIP1 complex. FNIP1 phosphorylation is required for AMPK to induce nuclear translocation of TFEB and TFEB-dependent increases of peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α) and estrogen-related receptor alpha (ERRα) messenger RNAs. Thus, mitochondrial damage triggers AMPK-FNIP1-dependent nuclear translocation of TFEB, inducing sequential waves of lysosomal and mitochondrial biogenesis.
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4P FAT1: A novel modulator of autophagy in human glioblastoma. ESMO Open 2023. [DOI: 10.1016/j.esmoop.2023.101016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study. Lancet Digit Health 2022; 4:e520-e531. [PMID: 35750401 DOI: 10.1016/s2589-7500(22)00069-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/07/2022] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. METHODS We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). FINDINGS In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]). INTERPRETATION In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. FUNDING British Journal of Surgery Society.
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Crizotinib in patients with tumors harboring ALK or ROS1 rearrangements in the NCI-MATCH trial. NPJ Precis Oncol 2022; 6:13. [PMID: 35233056 PMCID: PMC8888601 DOI: 10.1038/s41698-022-00256-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 12/16/2021] [Indexed: 01/14/2023] Open
Abstract
The NCI-MATCH was designed to characterize the efficacy of targeted therapies in histology-agnostic driver mutation-positive malignancies. Sub-protocols F and G were developed to evaluate the role of crizotinib in rare tumors that harbored either ALK or ROS1 rearrangements. Patients with malignancies that progressed following at least one prior systemic therapy were accrued to the NCI-MATCH for molecular profiling, and those with actionable ALK or ROS1 rearrangements were offered participation in sub-protocols F or G, respectively. There were five patients who enrolled on Arm F (ALK) and four patients on Arm G (ROS1). Few grade 3 or 4 toxicities were noted, including liver test abnormalities, and acute kidney injury. For sub-protocol F (ALK), the response rate was 50% (90% CI 9.8-90.2%) with one complete response among the 4 eligible patients. The median PFS was 3.8 months, and median OS was 4.3 months. For sub-protocol G (ROS1) the response rate was 25% (90% CI 1.3-75.1%). The median PFS was 4.3 months, and median OS 6.2 months. Data from 3 commercial vendors showed that the prevalence of ALK and ROS1 rearrangements in histologies other than non-small cell lung cancer and lymphoma was rare (0.1% and 0.4% respectively). We observed responses to crizotinib which met the primary endpoint for ALK fusions, albeit in a small number of patients. Despite the limited accrual, some of the patients with these oncogenic fusions can respond to crizotinib which may have a therapeutic role in this setting.
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1602 A Quality Improvement Project on The Management of Patients with Traumatic Head Injury Presenting to A District General Hospital. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Introduction
Traumatic Brain Injury (TBI) is associated with morbidity and mortality. All District General Hospitals (DGH) in West Midlands liaise with Neurosurgery centres for management of these patients through a referral system (NORSe). The aim of this study was to assess outcomes in TBI following the implementation of vital interventions.
Method
A retrospective data was collected between 1/1/2019 and 1/12/2020. We included all patients admitted with traumatic brain injury over the age of 16. We accessed the data from the hospital database, clinical notes, and NORSe. A re-audit was performed following implementations of recommendations (proforma and care of elderly input). Further data were collected prospectively.
Results
Our cohort included n1=61 patients (first cycle) and n2= 29 (second cycle). The demographic age and gender were comparable in both cycles. The median time for Neurosurgery advice was 229 minutes (IQR 60-690) in the first cycle as compared to 80 minutes (IQR 40-120, P < 0.05) and the main cause for delay was inadequate information transfer. The mortality rate was 24% (5 were attributed to sepsis), as compared to 14% in the second cycle. The median length of stay (LOS) was 4 days (IQR 3-13.5) in the first cycle, which translates to a cost of £26,815 per quarter. In comparison, LOS was 3 days (IQR 2-4), which translates to the cost of bed occupancy of £12,771 and saving of £14,043 per quarter, in the second cycle.
Conclusions
The introduction of simple interventions in a DGH can help to significantly improve patient outcomes in those admitted with Traumatic brain injury.
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Weight Management Interventions Delivered by a Dietitian for Adults with Overweight or Obesity: A Systematic Review. J Acad Nutr Diet 2021. [DOI: 10.1016/j.jand.2021.08.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in Pakistan: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. J Antimicrob Chemother 2021; 75:i76-i87. [PMID: 32337594 DOI: 10.1093/jac/dkaa085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To determine antibiotic susceptibility of community-acquired respiratory tract infection (CA-RTI) isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2015-17 from Pakistan. METHODS MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. RESULTS A total of 94 S. pneumoniae and 122 H. influenzae isolates were collected. Susceptibility to penicillin was noted in 23.4% of the S. pneumoniae isolates by CLSI oral/EUCAST low-dose IV breakpoints, although by CLSI IV and EUCAST high-dose breakpoints all isolates were characterized as susceptible. Susceptibility to trimethoprim/sulfamethoxazole (10.6%), macrolides (33%) and cefaclor (28.7%) was low but higher susceptibility was observed to ceftriaxone (100%), amoxicillin and amoxicillin/clavulanic acid (98.9%), cefuroxime (oral, 97.9%), cefpodoxime (96.8%), fluoroquinolones (93.6%-96.8%) and cefdinir (76.6%) by CLSI breakpoints. However, using EUCAST breakpoints, susceptibility to cefpodoxime (70.2%) and cefuroxime (oral, 61.7%) was reduced. H. influenzae isolates were almost all β-lactamase negative (96.7%). Using CLSI breakpoints, ≥93.4% of isolates were susceptible to all antibiotics tested except fluoroquinolones (75.4%-77.1%) and trimethoprim/sulfamethoxazole (41%). The proportion of isolates susceptible using EUCAST breakpoints was similar or identical for penicillins, trimethoprim/sulfamethoxazole and the cephalosporins that have EUCAST breakpoints; the proportion of isolates susceptible using EUCAST breakpoints was similar or identical to that using CSLI breakpoints except for cefuroxime (oral), where only 1.6% of isolates were considered susceptible. Susceptibility of H. influenzae to fluoroquinolones was also lower by EUCAST breakpoints (33.6%-34.4%). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. CONCLUSIONS Antibiotic susceptibility in these important respiratory tract pathogens varied in Pakistan based on different breakpoints. These data are important for empirical therapy choices in the treatment of CA-RTIs.
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AMPK/ULK1-mediated phosphorylation of Parkin ACT domain mediates an early step in mitophagy. SCIENCE ADVANCES 2021; 7:7/15/eabg4544. [PMID: 33827825 PMCID: PMC8026119 DOI: 10.1126/sciadv.abg4544] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/18/2021] [Indexed: 05/28/2023]
Abstract
The serine/threonine kinase ULK1 mediates autophagy initiation in response to various cellular stresses, and genetic deletion of ULK1 leads to accumulation of damaged mitochondria. Here we identify Parkin, the core ubiquitin ligase in mitophagy, and PARK2 gene product mutated in familial Parkinson's disease, as a ULK1 substrate. Recent studies uncovered a nine residue ("ACT") domain important for Parkin activation, and we demonstrate that AMPK-dependent ULK1 rapidly phosphorylates conserved serine108 in the ACT domain in response to mitochondrial stress. Phosphorylation of Parkin Ser108 occurs maximally within five minutes of mitochondrial damage, unlike activation of PINK1 and TBK1, which is observed thirty to sixty minutes later. Mutation of the ULK1 phosphorylation sites in Parkin, genetic AMPK or ULK1 depletion, or pharmacologic ULK1 inhibition, all lead to delays in Parkin activation and defects in assays of Parkin function and downstream mitophagy events. These findings reveal an unexpected first step in the mitophagy cascade.
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MRI-Radiomic Signature For Differentiating Low Grade Glioma From Glioblastoma Peritumoral Region. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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SBRT for Primary Head and Neck Cancers: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Quantitative Mapping of the Peritumoral Region to Demarcate Areas of Tumor Infiltration from Vasogenic Edema in Radiation Planning MRI of Glioblastoma Multiform (GBM). Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.2130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Decrease in cardiac catheterization and MI during COVID pandemic. ACTA ACUST UNITED AC 2020; 1:100001. [PMID: 34173587 PMCID: PMC7520383 DOI: 10.1016/j.ahjo.2020.100001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/01/2020] [Indexed: 10/30/2022]
Abstract
The consequences of severe acute viral respiratory syndrome (COVID 19) pandemic include collateral effects, one of which has been the significant reduction in routine hospital work. With widespread reports indicating reduction of cardiac procedures including MI presentation to hospitals, we aimed to analyze the local data over a 10-week period during lockdown in a tertiary cardiac centre Catheter Laboratory in England. Methods We conducted a retrospective review of the coronary catheterisation procedures and admissions with MI over the peak COVID-19 pandemic 10-week period (23rd March-30th May) in 2020, compared with the same 10-week period (25th March-2nd June) in 2019. Results In 2019, 539 patients were admitted to the Cath lab for coronary catheterisation (M = 385:F = 154; mean age 65 years; STEMI = 186, NSTEMI = 192, elective = 161). In 2020, during peak period of COVID19 pandemic in England, a total of 278 patients were admitted for coronary catheterisation over the 10-week period (M = 201:F = 77; mean age 60.5 years; STEMI = 132, NSTEMI = 118, elective = 28). During peak COVID19 pandemic, this represents a 48.4% drop in all coronary catheterisations. The reduction in STEMI was 29% (54 less), in NSTEMI was 38.9% (74 less) and elective procedures dropped by 83% (133 less). Conclusion During peak COVID hospital admission period in England, we report a 48.5% reduction in coronary catheterisation in our tertiary hospital. These results are consistent with reports from other countries, and highlight the worrying potential consequences for these patients arising from delays in presentation with MI, and the challenges for restoring services post-pandemic.
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Beyond Counting Macros: Are Common Fad Diets Nutritionally Adequate? An Examination of Their Micronutrient Content. J Acad Nutr Diet 2020. [DOI: 10.1016/j.jand.2020.06.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Microstructure and reconstitution of freeze-dried gum Arabic at a range of concentrations and primary drying temperatures. Food Hydrocoll 2020. [DOI: 10.1016/j.foodhyd.2020.105712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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P6256Revascularisation for acute coronary syndrome: are we offering elderly patients the correct treatment? Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Purpose
Acute coronary syndrome (ACS) is treated with revascularisation procedures such as percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Whilst reasonable clinical exclusion criteria exist, age is not one of them and patients of advanced years have been shown to have better outcomes with both treatments than with medical management. We set out to investigate the management and outcomes of patients age seventy five and over, with ACS.
Methods
A retrospective data analysis of all patients age seventy five and above, prescribed dual antiplatelet therapy (DAPT - aspirin plus clopidogrel or aspirin plus ticagrelor), admitted to our institution over a one year period (April 2015 to April 2016). We analysed electronic records and discharge documents and excluded patients without a diagnosis of ACS.
Results
207 patients over 75 years old were treated for ACS; 83.6% (173) were diagnosed with non ST elevation myocardial infarction (NSTEMI), 9.6% (20) diagnosed with ST elevation myocardial infarction (STEMI) and 6.8% (14) diagnosed with unstable angina. 73.4% (152) of patients were managed medically, 14.5% (30) had an angiogram, 11.1% (23) had PCI and 1.0% (2) had CABG. 74.0% (153) of patients were treated with aspirin plus clopidogrel, 26.0% (54) with aspirin plus ticagrelor. Major bleeds were reported in 21 patients (10.1%), 18 of the medically managed patients (8.7%) and 3 in the intervention group (5.5%) (P value 0.30). There were 17 major bleeds in the aspirin and clopidogrel group (11.1%) and 4 in the aspirin and ticagrelor group (7.4%) (P value 0.60). 93 (61.2%) of the medically treated group were alive at one year compared to 47 (85.5%) of the intervention group (P value 0.0008).
Conclusion
Our data show a clear survival benefit in the intervention group, although comparisons between the groups are challenging given confounding factors, such as co-morbidities and patient preference. However, the high proportion (73.4%) of over 75-years old treated medically warrants further evaluation, given the evidence of benefit for patients in this age group, treated with PCI. We feel there is a need for further research in to the ideas and practice surrounding the management of ACS in the over 75's, and their relation to the available evidence.
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Stereotactic Ablative Radiotherapy for Mediastinal and Hilar Lymphadenopathy: A Systematic Review. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pre-treatment Class Attendance and Outcomes in Head & Neck Cancer Patients Undergoing Radiation. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Regulation of programmed cell death 10 (PDCD10) by FAT1 gene in human glioblastoma. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy429.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bio‐based engineered nanocomposite foam with enhanced mechanical and thermal barrier properties. J Appl Polym Sci 2018. [DOI: 10.1002/app.47063] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Effect of freezing on microstructure and reconstitution of freeze-dried high solid hydrocolloid-based systems. Food Hydrocoll 2018. [DOI: 10.1016/j.foodhyd.2018.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Emerging role of FAT1 gene in the regulation of oncogenic miRNA 221/222- 3p in glioma. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy314.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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PO-141 FAT1 acts as an oncogene and regulate the expression of miR-221/222–3 p in glioblastoma. ESMO Open 2018. [DOI: 10.1136/esmoopen-2018-eacr25.665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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EP-1793: Establishing local confidence limit and the optimization of VMAT patient specific quality assurance. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)32102-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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P561Graphene based coating on bare metal stents improves human coronary artery endothelial cell growth. Cardiovasc Res 2018. [DOI: 10.1093/cvr/cvy060.415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Emphysematous Pyelonephritis and Cystitis in a Renal Transplant Recipient - Computed Tomographic Appearance. Int J Artif Organs 2018. [DOI: 10.1177/039139889301600109] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 35-year-old nondiabetic renal allograft recipient developed emphysematous pyelonephritis and cystitis emphysematosa necessitating graft nephrectomy. The patient received cyclosporin and prednisolone as immunosuppressive therapy. He developed the first episode of urinary tract infection one week after transplantation and another episode 3 months later. Abdominal CT scan revealed presence of gas in the graft kidney, urinary bladder, and surrounding tissues. Despite appropriate antibiotic therapy, his renal function deteriorated rapidly and he died on the first postoperative day.
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Insomnia: relationship with sleep quality and psychiatric disorders in patients with idiopathic pulmonary fibrosis. Sleep Med 2017. [DOI: 10.1016/j.sleep.2017.11.606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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32IMPROVED VERBAL COMMUNICATION BETWEEN PATIENTS, THEIR CAREGIVERS AND THE INTER-PROFESSIONAL TEAM THROUGH A PROCESS OF COMMUNICATION CLINICS: A FEASIBILITY STUDY. Age Ageing 2016. [DOI: 10.1093/ageing/afw024.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Endoscopic retrograde cholangiopancreatography (ERCP) outcomes can improve after further training for an individual already experienced in ERCP. MINERVA GASTROENTERO 2015; 61:117-120. [PMID: 26161565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This study was carried out to assess the impact of therapeutic endoscopy training on the endoscopic retrograde cholangiopancreatography (ERCP) practice of a physician who was practicing ERCP for many years in a community setting in the United States. A retrospective chart review of 390 ERCPs performed by the physician was accomplished; 176 and 214 ERCPs were performed before and after undergoing therapeutic endoscopy training respectively. Rates of common bile duct cannulation; postprocedure pancreatitis; use of common bile duct and pancreatic stents, as well as frequency of biliary and pancreatic sphincterotomies were assessed. The rate of common bile duct cannulation increased from 87% to 96% (P=0.008), while post-ERCP pancreatitis decreased from 8% to 3% (P=0.056), demonstrating that further guided experience in ERCP improved technical competency and decreased complications of ERCP for a physician already performing ERCPs independently in the USA.
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Abstract
OBJECTIVE To determine the rate of underestimation of malignancy in patients with biopsy-proven stromal fibrosis. METHODS Following institutional review board approval, we retrospectively reviewed the charts of patients with biopsy-proven stromal fibrosis who underwent percutaneous breast biopsy in the 5-year period between 1 January 2005 and 31 December 2009. The medical records and the histopathology in patients who underwent repeat biopsy and/or surgical excision at the site of stromal fibrosis within 2 years were reviewed. Interval stability for up to 2 years was documented in patients who did not undergo additional biopsy or surgical excision. An upgrade was defined as any patient with biopsy-proven stromal fibrosis or fibroadenoma with evidence of malignancy at the site of biopsy within 2 years. RESULTS 365 cases of stromal fibrosis were identified, of which 25 (7%) were upgraded to in situ or invasive malignancy on repeat biopsy or surgical excision. 7 were upgraded to ductal carcinoma in situ and 18 were upgraded to invasive cancer. Of the upgraded cases, 8 out of 24 (32%) were considered concordant with a benign diagnosis. The false-negative rate, that is, cases of stromal fibrosis concordant with benignity, but with subsequent upgrade, comprised 2% of all cases. CONCLUSION In biopsy-proven cases of stromal fibrosis, there is a 7% upgrade to malignancy. We recommend that all instances of stromal fibrosis with radiology-pathology discordance undergo repeat biopsy or surgical excision. Cases that demonstrate radiology-pathology concordance can be safely categorized as a Breast Imaging Reporting and Data System 3 (BI-RADS® 3) lesion with a 6-month follow-up, owing to a false-negative rate for missed cancer of 2%. ADVANCES IN KNOWLEDGE We now recommend that concordant cases of stromal fibrosis be categorized as BI-RADS 3 with a short-term follow-up, as this results in a missed cancer rate of 2%.
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Abstract
BACKGROUND High-fibre and low-carbohydrate diets may enhance satiety and promote weight loss. We compared a diet rich in beans aiming to increase dietary fibre and promote weight loss with a low-carbohydrate diet in a randomised controlled trial to assess effect and tolerability of the high-fibre bean-rich diet. METHODS AND RESULTS One hundred and seventy-three women and men, with a mean body mass index of approximately 36 kg m(-2) (one-fifth with diabetes type 2) were randomised to a high-fibre bean-rich diet that achieved mean (SD) fibre intakes of 35.5 (18.6) g day(-1) for women and 42.5 (30.3) g day(-1) for men, or a low-carbohydrate diet. Both diets were induced gradually over 4 weeks and included a 3-day feeding phase. Among 123 (71.1%) completers at 16 weeks, mean (SD) weight loss was 4.1 (4.0) kg in the high-fibre versus 5.2 (4.5) kg in the low-carbohydrate group [difference, 1.1 kg, 95% confidence interval (CI) = -2.6 to -0.5; P = 0.2], with results similar to the intent-to-treat population. Low-density lipoprotein (LDL)-cholesterol levels decreased with the high-fibre diet (difference in LDL-cholesterol versus low-carbohydrate diet, 0.2 mmol L(-1) , 95% CI = 0.01-0.44 mmol L(-1) ; P = 0.045), as did total cholesterol (P = 0.038), whereas changes in other lipids and glucose did not differ. After 52 weeks, the low-carbohydrate (n = 24) group tended to retain weight loss better than the high-fibre group (P = 0.06), although total cholesterol remained lower with the bean-rich diet (P = 0.049). CONCLUSIONS A high-fibre bean-rich diet was as effective as a low-carbohydrate diet for weight loss, although only the bean-rich diet lowered atherogenic lipids.
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Meadow Bromegrass and Crested Wheatgrass Forage Yield Response to Herbicides Applied during Establishment. ACTA ACUST UNITED AC 2013. [DOI: 10.2134/jpa1991.0508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
SAR models were developed for 12 rat tumour sites using data derived from the Carcinogenic Potency Database. Essentially, the models fall into two categories: Target Site Carcinogen-Non-Carcinogen (TSC-NC) and Target Site Carcinogen-Non-Target Site Carcinogen (TSC-NTSC). The TSC-NC models were composed of active chemicals that were carcinogenic to a specific target site and inactive ones that were whole animal non-carcinogens. On the other hand, the TSC-NTSC models used an inactive category also composed of carcinogens but to any/all other sites but the target site. Leave one out (LOO) validations produced an overall average concordance value for all 12 models of 0.77 for the TSC-NC models and 0.73 for the TSC-NTSC models. Overall, these findings suggest that while the TSC-NC models are able to distinguish between carcinogens and non-carcinogens, the TSC-NTSC models are identifying structural attributes that associate carcinogens to specific tumour sites. Since the TSC-NTSC models are composed of active and inactive compounds that are genotoxic and non-genotoxic carcinogens, the TSC-NTSC models may be capable of deciphering non-genotoxic mechanisms of carcinogenesis. Together, models of this type may also prove useful in anticancer drug development since they essentially contain chemical moieties that target a specific tumour site.
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028 Age related mortality of primary PCI patients at a high volume UK cardiac centre: Abstract 028 Figure 1. BRITISH HEART JOURNAL 2012. [DOI: 10.1136/heartjnl-2012-301877b.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Modified Hodge test: A simple and effective test for detection of carbapenemase production. IRANIAN JOURNAL OF MICROBIOLOGY 2011; 3:189-93. [PMID: 22530087 PMCID: PMC3330182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Resistance among bacterial isolates is the leading cause of increased mortality and morbidity worldwide. Carbapenems once thought to be effective are becoming ineffective mostly due to the emergence of carbapenemase. This study was designed to determine in vitro efficacy of Modified Hodge test for detection of carbapenemase production in Gram negative rods. MATERIAL AND METHODS The study was done in the Department of Microbiology, Armed Forces Institute of Pathology Rawalpindi Pakistan from January 2010 to December 2010. A total of 200 Gram negative rods from different clinical samples were taken. Those isolates which showed intermediate or susceptible zones i.e 16mm-21mm on disc diffusion were included in the study. These isolates were then subjected to Modified Hodge test. RESULT Out of 200 isolates, 138 (69%) were positive for carbapenemase production by Modified Hodge test. Out of 138 MHT positive organisms, the frequency of E. coli was 38%, followed by Pseudomonas aeruginosa (30%), Klebsiella pneumoniae (17%), Acinetobacter baumannii (12%), Citrobacter diversus (2%) and Enterobacter agglomerans (1.4%). CONCLUSION Modified Hodge test is a simple test which can be performed in the routine lab for detection of carbapenemases in isolates showing intermediate or sensitive zone diameter on disc diffusion.
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53 Effects Of GLP-1 eluting stem cell therapy on collagen remodelling in a porcine model of myocardial infarction. BRITISH HEART JOURNAL 2011. [DOI: 10.1136/heartjnl-2011-300920b.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Road traffic injuries in Rawalpindi city, Pakistan. EASTERN MEDITERRANEAN HEALTH JOURNAL = LA REVUE DE SANTE DE LA MEDITERRANEE ORIENTALE = AL-MAJALLAH AL-SIHHIYAH LI-SHARQ AL-MUTAWASSIT 2011; 17:647-653. [PMID: 22259914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Data on road traffic accident (RTA) injuries and their outcome are scarce in Pakistan. This study assessed patterns of RTA injuries reported in Rawalpindi city using standard surveillance methods. All RTA injury patients presenting to emergency departments of 3 tertiary care facilities from July 2007 to June 2008 were included. RTA injuries (n = 19 828) accounted for 31.7% of all injuries. Among children aged 0-14 years females suffered twice as many RTA injuries as males (21.3% versus 11.4%), whereas this trend reversed for the age group 15-24 years (41.9% versus 21.7%). One-fifth of injuries were either fractures or concussion. Severity and outcome of injuries were worse for the age group 45 years and older. For every road traffic death in Rawalpindi city, 29 more people were hospitalized and 177 more received emergency department care. These results suggest the need for better RTA injury surveillance to identify preventive and control measures for the increasingly high road disease burden in this city.
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Road traffic injuries in Rawalpindi city, Pakistan. EASTERN MEDITERRANEAN HEALTH JOURNAL 2011. [DOI: 10.26719/2011.17.9.647] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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30 Comparison of bivalirudin vs abciximab vs "unfractionated heparin only" for primary percutaneous coronary intervention in a high-volume centre. BRITISH HEART JOURNAL 2011. [DOI: 10.1136/heartjnl-2011-300198.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Cell receptor-ligand interaction, signalling, activation and apoptosis: 21. Pregnenolone Sulphate is Similar to Dexamethasone in Supressing the Unfettered Secretion of Hyaluronan: In Vitro Study on Cultured Synovial Fibroblasts from Patients with Longstanding Rheumatoid Arthritis. Rheumatology (Oxford) 2011. [DOI: 10.1093/rheumatology/ker032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Transient exposure of macrophages to P38 map kinase inhibition conditions cell responses through MAPK activated protein kinase-2 regulation. Ann Rheum Dis 2011. [DOI: 10.1136/ard.2010.148965.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Change in CA 19-9 Levels after Chemoradiotherapy Predicts Survival in Patients with Locally Advanced Unresectable Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2010. [DOI: 10.1016/j.ijrobp.2010.07.709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Evaluation of thin-layer agar 7H11 for the isolation of Mycobacterium tuberculosis complex. Int J Tuberc Lung Dis 2010; 14:1354-1356. [PMID: 20843431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
We evaluated the thin-layer agar (TLA) method for the recovery of Mycobacterium tuberculosis complex and compared the results with the BACTEC Mycobacteria Growth Indicator Tube (MGIT) 960 system. A total of 53 mycobacterial isolates were isolated on both media. The recovery rates of mycobacteria on TLA and BACTEC MGIT 960 system were respectively 90.6% and 96.2%. Mean time to detection of mycobacteria on TLA was 12.5 compared to 11.2 days on BACTEC MGIT 960. TLA is a simple technique and can be used as an alternative to the Löwenstein-Jensen medium and BACTEC MGIT 960 for the isolation of mycobacteria in resource-poor settings.
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YIA6 Effects of GLP-1 eluting stem cell therapy on collagen remodelling, infarct size and apoptosis in a porcine model of myocardial infarction. BRITISH HEART JOURNAL 2010. [DOI: 10.1136/hrt.2010.205781.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Sunday, 18 July 2010. Cardiovasc Res 2010. [DOI: 10.1093/cvr/cvq176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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P33 A NUTRIGENOMIC APPROACH TO STUDY THE EFFECT OF HERBAL POLYPHENOLS ON ATHEROGENIC TRANSCRIPTOME. ATHEROSCLEROSIS SUPP 2010. [DOI: 10.1016/s1567-5688(10)70100-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Reply to D Shome et al. Eye (Lond) 2008; 22:1197-8; author reply 1198. [DOI: 10.1038/sj.eye.6703059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Abstract
BACKGROUND Antiglucocorticoids may have antidepressant effects and have been reported to be efficacious in the treatment of severe psychiatric disorders. The efficacy and safety of antiglucocorticoid treatments for mood disorders is the subject of this systematic review. OBJECTIVES To compare the efficacy and safety of antiglucocorticoid agents in the treatment of mood episodes (manic, mixed affective or depressive) with placebo or alternative drug treatment in mood disorders. SEARCH STRATEGY CCDANCTR-Studies and CCDANCTR-References were searched on 11-9-2007. Additional searches of electronic databases were conducted in December 2006. Conference proceedings were searched. Experts and pharmaceutical companies were contacted. SELECTION CRITERIA Randomised controlled trials comparing antiglucocorticoid drugs in the treatment of mood episodes with placebo or alternative drug treatment in mood disorders were selected. DATA COLLECTION AND ANALYSIS Data were extracted and the methodological quality of each study was assessed independently by two review authors. Meta-analyses were performed using Review Manager software. Relative risk (RR) with 95% confidence intervals (CI) were calculated for dichotomous outcomes. For continuous data, weighted mean differences (WMD) were calculated. MAIN RESULTS Nine studies met criteria for inclusion. A number of drugs were examined, including mifepristone [RU-486], ketoconazole, metyrapone and DHEA. Three trials were in patients with psychotic major depression (pMDD), five trials in non-psychotic major depression and one trial in bipolar disorder. When examining all trials together across all affective episodes, there was no significant difference in the overall proportion of patients responding to antiglucocorticoid treatment over placebo, although the mean change in HAM-D scores indicated a significant difference in favour of treatment (WMD -4.54, 95%CI -6.78 to -2.29). Of the five trials in non-psychotic depression (unipolar or bipolar), there was a significant difference favouring treatment (HAM-D 50% reduction: RR 0.72, 95%CI 0.56 to 0.91). In pMDD, there was no evidence of an overall antidepressant effect (HAM-D 50% reduction: RR 0.98, 95%CI 0.79 to 1.22) or an effect on overall psychopathology (BPRS 30% reduction: RR 0.96, 95%CI 0.76 to 1.22). In these subtypes, the mean change in HAM-D indicated a significant difference in favour of treatment. AUTHORS' CONCLUSIONS The use of antiglucocorticoids in the treatment of mood disorders is at the proof-of-concept stage. Considerable methodological differences exist between studies with respect to the compounds used and the patient cohorts studied. Results in some diagnostic subtypes are promising and warrant further investigation to establish the clinical utility of these drugs in the treatment of mood disorders.
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