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Davies TW, Kelly E, van Gassel RJJ, van de Poll MCG, Gunst J, Casaer MP, Christopher KB, Preiser JC, Hill A, Gundogan K, Reintam-Blaser A, Rousseau AF, Hodgson C, Needham DM, Schaller SJ, McClelland T, Pilkington JJ, Sevin CM, Wischmeyer PE, Lee ZY, Govil D, Chapple L, Denehy L, Montejo-González JC, Taylor B, Bear DE, Pearse RM, McNelly A, Prowle J, Puthucheary ZA. A systematic review and meta-analysis of the clinimetric properties of the core outcome measurement instruments for clinical effectiveness trials of nutritional and metabolic interventions in critical illness (CONCISE). Crit Care 2023; 27:450. [PMID: 37986015 PMCID: PMC10662687 DOI: 10.1186/s13054-023-04729-7] [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: 09/14/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND CONCISE is an internationally agreed minimum set of outcomes for use in nutritional and metabolic clinical research in critically ill adults. Clinicians and researchers need to be aware of the clinimetric properties of these instruments and understand any limitations to ensure valid and reliable research. This systematic review and meta-analysis were undertaken to evaluate the clinimetric properties of the measurement instruments identified in CONCISE. METHODS Four electronic databases were searched from inception to December 2022 (MEDLINE via Ovid, EMBASE via Ovid, CINAHL via Healthcare Databases Advanced Search, CENTRAL via Cochrane). Studies were included if they examined at least one clinimetric property of a CONCISE measurement instrument or recognised variation in adults ≥ 18 years with critical illness or recovering from critical illness in any language. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for systematic reviews of Patient-Reported Outcome Measures was used. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in line with COSMIN guidance. The COSMIN checklist was used to evaluate the risk of bias and the quality of clinimetric properties. Overall certainty of the evidence was rated using a modified Grading of Recommendations, Assessment, Development and Evaluation approach. Narrative synthesis was performed and where possible, meta-analysis was conducted. RESULTS A total of 4316 studies were screened. Forty-seven were included in the review, reporting data for 12308 participants. The Short Form-36 Questionnaire (Physical Component Score and Physical Functioning), sit-to-stand test, 6-m walk test and Barthel Index had the strongest clinimetric properties and certainty of evidence. The Short Physical Performance Battery, Katz Index and handgrip strength had less favourable results. There was limited data for Lawson Instrumental Activities of Daily Living and the Global Leadership Initiative on Malnutrition criteria. The risk of bias ranged from inadequate to very good. The certainty of the evidence ranged from very low to high. CONCLUSIONS Variable evidence exists to support the clinimetric properties of the CONCISE measurement instruments. We suggest using this review alongside CONCISE to guide outcome selection for future trials of nutrition and metabolic interventions in critical illness. TRIAL REGISTRATION PROSPERO (CRD42023438187). Registered 21/06/2023.
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Affiliation(s)
- T W Davies
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK.
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK.
| | - E Kelly
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - R J J van Gassel
- Department of Intensive Care Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - M C G van de Poll
- Department of Intensive Care Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J Gunst
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - M P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - K B Christopher
- Division of Renal Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - J C Preiser
- Medical Direction, Erasme University Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - A Hill
- Department of Intensive Care Medicine, University Hospital RWTH, 52074, Aachen, Germany
- Department of Anesthesiology, University Hospital RWTH, 52074, Aachen, Germany
| | - K Gundogan
- Division of Intensive Care Medicine, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey
| | - A Reintam-Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - A-F Rousseau
- Department of Intensive Care, University Hospital of Liège, Liege, Belgium
| | - C Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 3/553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - D M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA
- Pulmonary and Critical Care Medicine, Department of Medicine, and Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S J Schaller
- Department of Anesthesiology and Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin Institute of Health, Berlin, Germany
- Department of Anesthesiology and Intensive Care, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - T McClelland
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - J J Pilkington
- Centre for Bioscience, Manchester Metropolitan University, John Dalton Building, Chester Street, Manchester, UK
| | - C M Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - P E Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, DUMC, Box 3094 Mail # 41, 2301 Erwin Road, Durham, NC, 5692 HAFS27710, USA
| | - Z Y Lee
- Department of Anesthesiology, University of Malaya, Kuala Lumpur, Malaysia
- Department of Cardiac, Anesthesiology & Intensive Care Medicine, Charité, Berlin, Germany
| | - D Govil
- Institute of Critical Care and Anesthesia, Medanta: The Medicty, Gurugram, Haryana, India
| | - L Chapple
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - L Denehy
- School of Health Sciences, The University of Melbourne, Melbourne, Australia
- Department of Allied Health, Peter McCallum Cancer Centre, Melbourne, Australia
| | - J C Montejo-González
- Instituto de Investigación I+12, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - B Taylor
- Department of Research for Patient Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - D E Bear
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - R M Pearse
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - A McNelly
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| | - J Prowle
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - Z A Puthucheary
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
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Wilkinson D, Gallagher IJ, McNelly A, Bear DE, Hart N, Montgomery HE, Le Guennec A, Conte MR, Francis T, Harridge SDR, Atherton PJ, Puthucheary ZA. The metabolic effects of intermittent versus continuous feeding in critically ill patients. Sci Rep 2023; 13:19508. [PMID: 37945671 PMCID: PMC10636009 DOI: 10.1038/s41598-023-46490-5] [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: 04/15/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023] Open
Abstract
Intermittent (or bolus) feeding regimens in critically ill patients have been of increasing interest to clinicians and scientists. Changes in amino acid, fat and carbohydrate metabolites over time might yet deliver other benefits (e.g. modulation of the circadian rhythm and sleep, and impacts on ghrelin secretion, insulin resistance and autophagy). We set out to characterise these changes in metabolite concentration. The Intermittent versus Continuous Feeding in Critically Ill paitents study (NCT02358512) was an eight-centre single-blinded randomised controlled trial. Patients were randomised to received a continuous (control arm) or intermittent (6x/day, intervention arm) enteral feeding regimen. Blood samples were taken on trial days 1, 7 and 10 immediately before and 30 min after intermittent feeds, and at equivalent timepoints in the control arm. A pre-planned targeted metabolomic analysis was performend using Nuclear Resonance Spectroscopy. Five hundred and ninety four samples were analysed from 75 patients. A total of 24 amino acid-, 19 lipid based-, and 44 small molecule metabolite features. Across the main two axes of variation (40-60% and 6-8% of variance), no broad patterns distinguished between intermittent or continuous feeding arms, across intra-day sampling times or over the 10 days from initial ICU admission. Logfold decreases in abundance were seen in metabolites related to amino acids (Glutamine - 0.682; Alanine - 0.594), ketone body metabolism (Acetone - 0.64; 3-Hydroxybutyric Acid - 0.632; Acetonacetic Acid - 0.586), fatty acid (carnitine - 0.509) and carbohydrate metabolism ( Maltose - 0.510; Citric Acid - 0.485). 2-3 Butanediol, a by-product of sugar-fermenting microbial metabolism also decreased (- 0.489). No correlation was seen with change in quadriceps muscle mass for any of the 20 metabolites varying with time (all p > 0.05). Increasing severity of organ failure was related to increasing ketone body metabolism (3 Hydroxybutyric Acid-1 and - 3; p = 0.056 and p = 0.014), carnitine deficiency (p = 0.002) and alanine abundancy (p - 0.005). A 6-times a day intermittent feeding regimen did not alter metabolite patterns across time compared to continuous feeding in critically ill patients, either within a 24 h period or across 10 days of intervention. Future research on intermittent feeding regimens should focus on clinical process benefits, or extended gut rest and fasting.
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Affiliation(s)
- D Wilkinson
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Metabolic and Molecular Physiology, University of Nottingham, Queen's Medical Cetnre, Nottingham, UK
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottinghan University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
| | | | - A McNelly
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - D E Bear
- Department of Nutrition and Dietetics St Thomas' NHS Foundation Trust, London, UK
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation & King's College London (KCL) NIHR BRC, London, UK
- Centre for Human and Applied Physiological Science, King's College London, London, UK
| | - N Hart
- Lane Fox Respiratory Service, Guy's & St Thomas' Foundation Trust, London, UK
- Lane Fox Clinical Respiratory Physiology Research Centre, Kings College London, London, UK
| | - H E Montgomery
- Department of Medicine and Centre for Human Health and Performance, University College London (UCL), London, UK
| | - A Le Guennec
- Centre for Biomolecular Spectroscopy, Guy's Campus, King's College London, London, UK
- Randall Centre for Cell and Molecular Biophysics, Guy's Campus, King's College London, London, UK
| | - M R Conte
- Centre for Biomolecular Spectroscopy, Guy's Campus, King's College London, London, UK
- Randall Centre for Cell and Molecular Biophysics, Guy's Campus, King's College London, London, UK
| | - T Francis
- Centre for Human and Applied Physiological Science, King's College London, London, UK
| | - S D R Harridge
- Centre for Human and Applied Physiological Science, King's College London, London, UK
| | - P J Atherton
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Metabolic and Molecular Physiology, University of Nottingham, Queen's Medical Cetnre, Nottingham, UK
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottinghan University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - Z A Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
- Randall Centre for Cell and Molecular Biophysics, Guy's Campus, King's College London, London, UK.
- Adult Critical Care Unit, Royal London Hospital, Whitechapel, London, E1 1BB, UK.
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Davies TW, van Gassel RJJ, van de Poll M, Gunst J, Casaer MP, Christopher KB, Preiser JC, Hill A, Gundogan K, Reintam-Blaser A, Rousseau AF, Hodgson C, Needham DM, Castro M, Schaller S, McClelland T, Pilkington JJ, Sevin CM, Wischmeyer PE, Lee ZY, Govil D, Li A, Chapple L, Denehy L, Montejo-González JC, Taylor B, Bear DE, Pearse R, McNelly A, Prowle J, Puthucheary ZA. Core outcome measures for clinical effectiveness trials of nutritional and metabolic interventions in critical illness: an international modified Delphi consensus study evaluation (CONCISE). Crit Care 2022; 26:240. [PMID: 35933433 PMCID: PMC9357332 DOI: 10.1186/s13054-022-04113-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [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: 05/25/2022] [Accepted: 07/25/2022] [Indexed: 01/06/2023] Open
Abstract
Background Clinical research on nutritional and metabolic interventions in critically ill patients is heterogenous regarding time points, outcomes and measurement instruments used, impeding intervention development and data syntheses, and ultimately worsening clinical outcomes. We aimed to identify and develop a set of core outcome domains and associated measurement instruments to include in all research in critically ill patients.
Methods An updated systematic review informed a two-stage modified Delphi consensus process (domains followed by instruments). Measurement instruments for domains considered ‘essential’ were taken through the second stage of the Delphi and a subsequent consensus meeting. Results In total, 213 participants (41 patients/caregivers, 50 clinical researchers and 122 healthcare professionals) from 24 countries contributed. Consensus was reached on time points (30 and 90 days post-randomisation). Three domains were considered ‘essential’ at 30 days (survival, physical function and Infection) and five at 90 days (survival, physical function, activities of daily living, nutritional status and muscle/nerve function). Core ‘essential’ measurement instruments reached consensus for survival and activities of daily living, and ‘recommended’ measurement instruments for physical function, nutritional status and muscle/nerve function. No consensus was reached for a measurement instrument for Infection. Four further domains met criteria for ‘recommended,’ but not ‘essential,’ to measure at 30 days post-randomisation (organ dysfunction, muscle/nerve function, nutritional status and wound healing) and three at 90 days (frailty, body composition and organ dysfunction). Conclusion The CONCISE core outcome set is an internationally agreed minimum set of outcomes for use at 30 and 90 days post-randomisation, in nutritional and metabolic clinical research in critically ill adults.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04113-x.
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Affiliation(s)
- T W Davies
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - R J J van Gassel
- Department of Intensive Care Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands.,Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - M van de Poll
- Department of Intensive Care Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands.,Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J Gunst
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - M P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - K B Christopher
- Division of Renal Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, USA
| | - J C Preiser
- Medical Direction, Erasme University Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - A Hill
- Departments of Intensive Care and Anesthesiology, University Hospital RWTH Aachen University, 52074, Aachen, Germany
| | - K Gundogan
- Division of Intensive Care Medicine, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey
| | - A Reintam-Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.,Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - A F Rousseau
- Department of Intensive Care, University Hospital of Liège, Liege, Belgium
| | - C Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 3/553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - D M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA.,Pulmonary and Critical Care Medicine, Department of Medicine, and Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M Castro
- Clinical Nutrition, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - S Schaller
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin Institute of Health, Berlin, Germany.,School of Medicine, Klinikum Rechts Der Isar, Department of Anesthesiology and Intensive Care, Technical University of Munich, Munich, Germany
| | - T McClelland
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - J J Pilkington
- Centre for Bioscience, Manchester Metropolitan University, John Dalton Building, Chester Street, Manchester, UK
| | - C M Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - P E Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, DUMC, Box 3094 Mail # 41, 2301 Erwin Road, Durham, NC, 5692 HAFS27710, USA
| | - Z Y Lee
- Department of Anesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | - D Govil
- Institute of Critical Care and Anesthesia, Medanta: The Medicty, Gurugram, Haryana, India
| | - A Li
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore.,Department of Intensive Care Medicine, Woodlands Health, Singapore, Singapore
| | - L Chapple
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - L Denehy
- The University of Melbourne, School of Health Sciences, Melbourne, Australia.,Department of Allied Health, Peter McCallum Cancer Centre, Melbourne, Australia
| | - J C Montejo-González
- Department of Intensive Care Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - B Taylor
- Department of Research for Patient Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - D E Bear
- Department of Critical Care and Department of Nutrition and Dietetics, Guy´S and St Thomas' NHS Foundation Trust, London, UK
| | - R Pearse
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - A McNelly
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - J Prowle
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - Z A Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK. .,Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK.
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