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Chisholm J, Mandeville H, Adams M, Minard-Collin V, Rogers T, Kelsey A, Shipley J, van Rijn RR, de Vries I, van Ewijk R, de Keizer B, Gatz SA, Casanova M, Hjalgrim LL, Firth C, Wheatley K, Kearns P, Liu W, Kirkham A, Rees H, Bisogno G, Wasti A, Wakeling S, Heenen D, Tweddle DA, Merks JHM, Jenney M. Frontline and Relapsed Rhabdomyosarcoma (FAR-RMS) Clinical Trial: A Report from the European Paediatric Soft Tissue Sarcoma Study Group (EpSSG). Cancers (Basel) 2024; 16:998. [PMID: 38473359 DOI: 10.3390/cancers16050998] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
The Frontline and Relapsed Rhabdomyosarcoma (FaR-RMS) clinical trial is an overarching, multinational study for children and adults with rhabdomyosarcoma (RMS). The trial, developed by the European Soft Tissue Sarcoma Study Group (EpSSG), incorporates multiple different research questions within a multistage design with a focus on (i) novel regimens for poor prognostic subgroups, (ii) optimal duration of maintenance chemotherapy, and (iii) optimal use of radiotherapy for local control and widespread metastatic disease. Additional sub-studies focusing on biological risk stratification, use of imaging modalities, including [18F]FDG PET-CT and diffusion-weighted MRI imaging (DWI) as prognostic markers, and impact of therapy on quality of life are described. This paper forms part of a Special Issue on rhabdomyosarcoma and outlines the study background, rationale for randomisations and sub-studies, design, and plans for utilisation and dissemination of results.
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Affiliation(s)
- Julia Chisholm
- Children and Young People's Unit, Royal Marsden Hospital and Institute of Cancer Research, Sutton SM2 5PT, UK
| | - Henry Mandeville
- Children and Young People's Unit, Royal Marsden Hospital and Institute of Cancer Research, Sutton SM2 5PT, UK
| | | | | | - Timothy Rogers
- Department of Paediatric Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 3NU, UK
| | - Anna Kelsey
- Department of Paediatric Histopathology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
| | - Janet Shipley
- The Institute of Cancer Research, London SW7 3RP, UK
| | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam UMC, 1081 HV Amsterdam, The Netherlands
| | - Isabelle de Vries
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
| | - Roelof van Ewijk
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
| | - Bart de Keizer
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
| | - Susanne A Gatz
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham B15 2TG, UK
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | | | | | - Charlotte Firth
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Pamela Kearns
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Wenyu Liu
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Amanda Kirkham
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Helen Rees
- Department of Paediatric Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 3NU, UK
| | - Gianni Bisogno
- Department of Women and Children's Health, University of Padova, 35122 Padua, Italy
| | - Ajla Wasti
- The Institute of Cancer Research, London SW7 3RP, UK
| | | | | | - Deborah A Tweddle
- Vivo Biobank, Translational & Clinical Research Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Johannes H M Merks
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
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Barnes E, Goodyear CS, Willicombe M, Gaskell C, Siebert S, I de Silva T, Murray SM, Rea D, Snowden JA, Carroll M, Pirrie S, Bowden SJ, Dunachie SJ, Richter A, Lim Z, Satsangi J, Cook G, Pope A, Hughes A, Harrison M, Lim SH, Miller P, Klenerman P, Basu N, Gilmour A, Irwin S, Meacham G, Marjot T, Dimitriadis S, Kelleher P, Prendecki M, Clarke C, Mortimer P, McIntyre S, Selby R, Meardon N, Nguyen D, Tipton T, Longet S, Laidlaw S, Orchard K, Ireland G, Thomas D, Kearns P, Kirkham A, McInnes IB. SARS-CoV-2-specific immune responses and clinical outcomes after COVID-19 vaccination in patients with immune-suppressive disease. Nat Med 2023; 29:1760-1774. [PMID: 37414897 PMCID: PMC10353927 DOI: 10.1038/s41591-023-02414-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [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: 08/05/2022] [Accepted: 05/23/2023] [Indexed: 07/08/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immune responses and infection outcomes were evaluated in 2,686 patients with varying immune-suppressive disease states after administration of two Coronavirus Disease 2019 (COVID-19) vaccines. Overall, 255 of 2,204 (12%) patients failed to develop anti-spike antibodies, with an additional 600 of 2,204 (27%) patients generating low levels (<380 AU ml-1). Vaccine failure rates were highest in ANCA-associated vasculitis on rituximab (21/29, 72%), hemodialysis on immunosuppressive therapy (6/30, 20%) and solid organ transplant recipients (20/81, 25% and 141/458, 31%). SARS-CoV-2-specific T cell responses were detected in 513 of 580 (88%) patients, with lower T cell magnitude or proportion in hemodialysis, allogeneic hematopoietic stem cell transplantation and liver transplant recipients (versus healthy controls). Humoral responses against Omicron (BA.1) were reduced, although cross-reactive T cell responses were sustained in all participants for whom these data were available. BNT162b2 was associated with higher antibody but lower cellular responses compared to ChAdOx1 nCoV-19 vaccination. We report 474 SARS-CoV-2 infection episodes, including 48 individuals with hospitalization or death from COVID-19. Decreased magnitude of both the serological and the T cell response was associated with severe COVID-19. Overall, we identified clinical phenotypes that may benefit from targeted COVID-19 therapeutic strategies.
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Affiliation(s)
- Eleanor Barnes
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Carl S Goodyear
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
| | - Michelle Willicombe
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, UK
| | - Charlotte Gaskell
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, UK
| | - Stefan Siebert
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
| | - Thushan I de Silva
- Department of Infection, Immunity and Cardiovascular Disease, The Medical School, The University of Sheffield, Sheffield, UK
| | - Sam M Murray
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Daniel Rea
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, UK
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Miles Carroll
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Sarah Pirrie
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, UK
| | - Sarah J Bowden
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, UK
| | - Susanna J Dunachie
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alex Richter
- Clinical Immunology Service, University of Birmingham, Edgbaston, Birmingham, UK
| | - Zixiang Lim
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jack Satsangi
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gordon Cook
- National Institute for Health Research, Leeds MIC, University of Leeds, Leeds, UK
| | - Ann Pope
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, UK
| | - Ana Hughes
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, UK
| | - Molly Harrison
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, UK
| | - Sean H Lim
- Centre for Cancer Immunology, University of Southampton, Southampton, UK
| | - Paul Miller
- British Society of Blood and Marrow Transplantation and Cellular Therapy, Guy's Hospital, London, UK
| | - Paul Klenerman
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Neil Basu
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
| | - Ashley Gilmour
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
| | - Sophie Irwin
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Georgina Meacham
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas Marjot
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Peter Kelleher
- Department of Infectious Diseases, Imperial College London, School of Medicine Chelsea and Westminster Hospital, London, UK
| | - Maria Prendecki
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, UK
| | - Candice Clarke
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, UK
| | - Paige Mortimer
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, UK
| | - Stacey McIntyre
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, UK
| | - Rachael Selby
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Naomi Meardon
- Department of Infection, Immunity and Cardiovascular Disease, The Medical School, The University of Sheffield, Sheffield, UK
| | - Dung Nguyen
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Tom Tipton
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Stephanie Longet
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Stephen Laidlaw
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Kim Orchard
- Department of Haematology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Georgina Ireland
- UK Health Security Agency (UKHSA), Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, London, UK
| | - David Thomas
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, UK
| | - Pamela Kearns
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, UK
- National Institute for Health Research Birmingham Biomedical Research Centre, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Amanda Kirkham
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, UK
| | - Iain B McInnes
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK.
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McIntosh SA, Coles CE, Dodwell D, Elder K, Foster J, Gaunt C, Kirkham A, Lyburn I, Morgan J, Pinder SE, Pirrie S, Potter S, Roberts T, Sharma N, Stobart H, Southgate E, Taylor-Phillips S, Wallis M, Rea D, Paramasivan S. Abstract P6-05-17: Recruitment challenges in a UK surgical de-escalation study: preliminary qualitative research findings from the SMALL trial. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p6-05-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background SMALL (ISRCTN 12240119) is a novel UK phase III multicentre randomised trial comparing vacuum-assisted excision (VAE) to surgery for small screen-detected breast cancers with biologically favourable characteristics. Acceptance by the clinical community and recruitment to SMALL was anticipated to be challenging as it involves randomisation, surgical de-escalation and minimally-invasive percutaneous treatment (VAE). A QuinteT Recruitment Intervention (QRI) has therefore been integrated throughout SMALL’s recruitment period, with the aim of optimising recruitment and informed consent. Methods The QRI in SMALL has involved the analysis of: a) screening log data b) written views from recruiters on the two treatments and their advantages/disadvantages c) in-depth semi-structured interviews with members of the Trial Management Group (TMG) and clinician-recruiters and d) audio-recordings of recruitment discussions with potentially eligible patients. Recruitment challenges were identified and addressed through the provision of written recruitment tips documents, and group and individual feedback sessions with recruiters. Results There was widespread support for the concept of the SMALL trial within the clinical community. Recruiters recognised the pioneering role of SMALL as the only current surgical de-escalation randomised trial in screen-detected breast cancer. Key recruitment challenges revolved around i) healthcare professionals (HCPs) who met patients early in the pathway providing information indicating that they were being referred for surgery (without mentioning SMALL or VAE), ii) concerns around the balance of de-escalation/escalation of different treatment modalities (e.g. some clinicians may prefer to de-escalate radiotherapy in preference to surgery in low-risk patients), iii) challenges in articulating equipoise in a surgical de-escalation trial, iv) patient preferences (primarily for surgery) and recruiter discomfort in exploring/addressing such preferences and v) fewer eligible patients than anticipated. QRI actions to overcome these issues included developing a tips document for HCPs meeting patients early in the pathway, highlighting the need to refrain from making treatment recommendations. A more generic tips document was also developed emphasising the importance of the early introduction of the study, provision of balanced information about both treatments, encouraging recruiters to engage with patients’ concerns and preferences, and adequate explanation of randomisation. Group and individual feedback sessions focussed on two key areas – articulating equipoise through balanced information provision, and considering optimal ways to explore patient preferences where they are expressed. Despite the many set-up and recruitment challenges that arose from opening at the start of the pandemic, SMALL has recruited 142 patients to date from 23 sites, with an approached to randomised patient ratio of ~50%. Conclusion SMALL is a novel surgical de-escalation study in breast cancer, which will provide critical evidence to support reductions in treatment of good prognosis disease. Using a range of qualitative methodology, the QRI has identified both broad support for the study within the clinical community, but has also identified barriers to recruitment at both clinician and patient level. These challenges have been addressed employing a range of methods, and the recruitment level and approach/randomised ratio shows the overall acceptability of this study to patients. Further work will involve interviews with patients, with a focus on their views on de-escalation, and further recruiter feedback sessions. Taken together, theis data will help inform the development and design of future de-escalation and treatment optimisation studies in breast cancer. SMALL is funded by the UK NIHR HTA programme, award 17/42/32
Citation Format: Stuart A. McIntosh, Charlotte E. Coles, David Dodwell, Kenneth Elder, Jessica Foster, Claire Gaunt, Amanda Kirkham, Iain Lyburn, Jenna Morgan, Sarah E. Pinder, Sarah Pirrie, Shelley Potter, Tracy Roberts, Nisha Sharma, Hilary Stobart, Elizabeth Southgate, Sian Taylor-Phillips, Matthew Wallis, Daniel Rea, Sangeetha Paramasivan. Recruitment challenges in a UK surgical de-escalation study: preliminary qualitative research findings from the SMALL trial [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-17.
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Affiliation(s)
| | | | | | | | | | | | | | - Iain Lyburn
- 8Gloucestershire University Hospitals NHS Trust
| | | | - Sarah E. Pinder
- 10School of Cancer and Pharmaceutical Sciences, King’s College London Faculty of Life Sciences and Medicine, London, London, England, United Kingdom
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Nay I, Hutchinson D, Rondina M, Kim K, Kroencke R, Kirkham A, Trujillo T, Tolley ND, Munger M. Prospective, randomized, controlled, trial to assess ASA DOSing by body mass index in HEalthy volunteers (DOSE study). Pharmacotherapy 2023; 43:215-225. [PMID: 36755519 DOI: 10.1002/phar.2777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/30/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
Abstract
STUDY OBJECTIVE: Aspirin (ASA) has demonstrated inconsistent results in primary prevention of cardiovascular disease (CVD). Guidelines are also inconsistent in the recommendation of routine ASA use for primary prevention of CVD, but advocate dosing as a "one-size-fits-all" approach. DESIGN An intention-to-treat, double-blind, randomized, controlled, clinical trial comparing three treatment arms of ASA 81, 325, and 500 mg daily dosed for 14 days were evenly randomized across the dosing categories to measure the impact of dosing by body mass index (BMI) (20-24.9, 25-29.9, ≥30 kg/m2 ) on ASA anti-platelet effects. SETTING University Ambulatory Clinic. PATIENTS Healthy volunteers defined as individuals who were medication free without acute or chronic significant health problems. INTERVENTION Change in ASA reactivity unit (ARU), salicylate levels, and thromboxane B2 (TxB2) levels were measured across BMI dosing categories and time. MAIN RESULTS: Fifty-four participants with a mean (±SD) age of 34.4 ± 10.9 years (M:F; 23:31) completed the study. Baseline ARU and TxB2 levels were not significantly different between obese and non-obese individuals. BMI was not a predictor of platelet inhibition. There was no interaction between gender and platelet activation at baseline or following ASA treatment. ASA 81 mg was associated with a lower ARU response (approximate 50% lower response) than either the 325-mg or the 500-mg doses of ASA. TxB2 and salicylate levels exhibited lower trends at 81 mg compared with higher doses. CONCLUSIONS In healthy male and female participants administered ASA for 14 days, obesity is not associated with increased basal platelet activation or ASA resistance. ASA 81 mg was significantly less effective in reducing platelet aggregation compared with ASA 325 and 500 mg, independent of BMI.
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Affiliation(s)
- Isaac Nay
- Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah, USA
| | - Doug Hutchinson
- Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah, USA
| | - Matthew Rondina
- Molecular Medicine Program, Salt Lake City, Utah, USA.,Departments of Internal Medicine and Pathology, Salt Lake City, Utah, USA
| | - Kibum Kim
- University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Rachel Kroencke
- University of Utah Associated Regional University Pathologists, University of Utah Health, Salt Lake City, Utah, USA
| | - Amanda Kirkham
- University of Utah Associated Regional University Pathologists, University of Utah Health, Salt Lake City, Utah, USA
| | - Toby Trujillo
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, Colorado, USA
| | - Neal D Tolley
- Molecular Medicine Program, Salt Lake City, Utah, USA
| | - Mark Munger
- Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah, USA.,University of Utah Associated Regional University Pathologists, University of Utah Health, Salt Lake City, Utah, USA
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McIntosh SA, Coles CE, Dodwell D, Elder K, Foster J, Gaunt C, Kirkham A, Lyburn I, Morgan J, Paramasivan S, Pinder SE, Pirrie S, Potter S, Roberts T, Sharma N, Stobart H, Southgate E, Taylor-Phillips S, Wallis M, Rea D. Abstract OT3-20-02: SMALL: Open Surgery versus Minimally invasive vacuum-Assisted excision for smaLL screen-detected breast cancer – a UK phase III randomised multi-centre trial. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-ot3-20-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: Mammographic screening programmes reduce breast cancer mortality, but detect many small tumours with favourable biological features which may not progress during a woman’s lifetime. Screen-detected cancers are treated with standard surgery and adjuvant therapies, with associated morbidities. There is a need to reduce overtreatment of good prognosis tumours and numerous studies have evaluated the omission of radiotherapy in this context. However, there is little evidence to support surgical de-escalation, although percutaneous minimally invasive treatment approaches have been described. Vacuum-assisted excision (VAE) is in widespread use for management of benign lesions and lesions of uncertain malignant potential. SMALL (ISRCTN 12240119) is designed to determine the feasibility of using this approach for treatment of small invasive tumours detected within the UK NHS Breast Screening Programme (BSP). Methods: SMALL is a phase III multicentre randomised trial comparing standard surgery with VAE for screen-detected good prognosis cancers. The main eligibility criteria are age ≥47 years, unifocal grade 1 tumours with maximum diameter 15mm, which are strongly ER/PR+ve and HER2-ve, with negative clinical/radiological axillary staging. Patients are randomised 2:1 in favour of VAE or surgery; with no axillary surgery in the VAE arm. Completeness of excision is assessed radiologically, and if excision is incomplete, patients undergo open surgery. Adjuvant radiotherapy and endocrine therapy are mandated in the VAE arm but may be omitted following surgery. Co-primary end-points are: 1. Non-inferiority comparison of the requirement for a second procedure following excision 2. Single arm analysis of local recurrence (LR) at 5 years following VAE Recruitment of 800 patients will permit demonstration of 10% non-inferiority of VAE for requirement of a second procedure. This ensures sufficient patients for single arm analysis of LR rates, where expected LR free survival is 99% at 5 years, with an undesirable survival probability after VAE of 97%. To ensure that the trial as a whole only has 5% alpha, the significance level for each co-primary outcome is set at 2.5% with 90% power. The Data Monitoring Committee will monitor LR events to ensure these do not exceed 3% per year. Secondary outcome measures include time to ipsilateral recurrence, overall survival, complications, quality of life and health economic analysis. A novel feature of SMALL is the integration of a QuinteT Recruitment Intervention (QRI), which aims to optimise recruitment to the study. Recruitment challenges are identified by analysing recruiter/patient interviews and audio-recordings of trial discussions, and by review of trial screening logs, eligibility and recruitment data and study documentation. Solutions to address these are developed collaboratively, including individual/group recruiter feedback and recruitment tips documents. Results: SMALL opened in December 2019, but recruitment halted in 2020 for 5 months due to COVID-19. At 7st July 2022, 142 patients had been randomised from 26 centres, with a randomisation rate of approximately 45%, and a per site recruitment rate of 0.4-0.5 patients/month, approaching the feasibility recruitment target of 144 patients. Drawing from preliminary QRI findings and insights from patient representatives, a recruitment tips document has been circulated (on providing balanced information about treatments, encouraging recruiters to engage with patient preferences, and explaining randomisation). Individual recruiter feedback has commenced, with wider feedback delivered across sites via recruitment training workshops. Conclusion: Despite pandemic-related challenges, SMALL has an excellent recruitment rate to date and is expected to have a global impact on treatment of breast cancer within mammographic screening programmes. SMALL is funded by the UK NIHR HTA programme, award 17/42/32
Citation Format: Stuart A. McIntosh, Charlotte E. Coles, David Dodwell, Kenneth Elder, Jessica Foster, Claire Gaunt, Amanda Kirkham, Iain Lyburn, Jenna Morgan, Sangeetha Paramasivan, Sarah E. Pinder, Sarah Pirrie, Shelley Potter, Tracy Roberts, Nisha Sharma, Hilary Stobart, Elizabeth Southgate, Sian Taylor-Phillips, Matthew Wallis, Daniel Rea. SMALL: Open Surgery versus Minimally invasive vacuum-Assisted excision for smaLL screen-detected breast cancer – a UK phase III randomised multi-centre trial [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT3-20-02.
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Affiliation(s)
| | | | | | | | | | | | | | - Iain Lyburn
- 8Gloucestershire University Hospitals NHS Trust
| | | | | | - Sarah E. Pinder
- 11School of Cancer and Pharmaceutical Sciences, King’s College London Faculty of Life Sciences and Medicine, London, London, England, United Kingdom
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6
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McIntosh S, Coles CE, Conefrey C, Dodwell DJ, Foster J, Gaunt C, Kirkham A, Lyburn I, Morgan J, Paramasivan S, Pinder SE, Pirrie S, Potter S, Roberts T, Sharma N, Stobart H, Southgate E, Taylor-Phillips S, Wallis M, Rea D. SMALL: Open surgery versus minimally invasive vacuum-assisted excision for small screen-detected breast cancers. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.tps614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS614 Background: Mammographic screening programmes reduce breast cancer mortality but detect many small tumours with favourable biology which may not progress. These are treated with surgery and adjuvant therapies, but associated morbidities mean there is a need to reduce overtreatment. Minimally invasive treatments such as vacuum-assisted excision (VAE) have been described but there is no prospective randomised evidence to support their routine use. SMALL (ISRCTN 12240119) is designed to establish the feasibility of using VAE to treat small tumours detected within the UK NHS Breast Screening Programme (BSP). Methods: Phase III multicenter randomized trial comparing surgery with VAE for screen-detected good prognosis cancers. Eligibility criteria are age ≥47 years, unifocal grade 1 tumors (maximum diameter 15mm), strongly ER/PR+ve and HER2-ve, with negative axillary staging. Patients are randomized 2:1 to VAE or surgery, with no axillary surgery in the VAE arm. Excision is assessed radiologically, and if incomplete, patients undergo surgery. Adjuvant radiotherapy and endocrine therapy are mandated in the VAE arm. Coprimary end-points are: (1) Non-inferiority comparison of the requirement for a second procedure. (2) Single-arm analysis of local recurrence (LR) at 5 years after VAE. Recruitment of 800 patients will permit demonstration of 10% non-inferiority of VAE for requirement of a second procedure, ensuring sufficient patients for single arm analysis of LR rates, where expected LR free survival is 99% at 5 years, with an undesirable survival probability after VAE of 97%. The DMC will monitor LR events to ensure these do not exceed 3% per year. Secondary outcome measures include time to ipsilateral recurrence, overall survival, complications, quality of life and health economic analysis. A QuinteT Recruitment Intervention (QRI) is integrated throughout SMALL to optimize recruitment and informed consent. Recruitment challenges are identified by analyzing recruiter/patient interviews, audio-recordings of trial discussions, and by review of screening, eligibility and recruitment data and study documentation. Solutions are developed collaboratively, including recruiter feedback and recruitment tips documents. Results: SMALL opened in December 2019, but recruitment halted for 5 months due to COVID-19. At 11th February 2022, 91 patients had been recruited from 22 centers, with an approached/consented ration of 50%. Drawing from preliminary QRI findings, a recruitment tips document has been circulated (on discussing SMALL, providing balanced information on treatment options and explaining randomization). Individual recruiter feedback has commenced, with wider feedback planned shortly. Conclusion: Despite pandemic-related challenges, SMALL has excellent recruitment to date and is expected to have a global impact on treatment of screen-detected breast cancer. Clinical trial information: 12240119.
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Affiliation(s)
| | | | | | | | | | - Claire Gaunt
- University of Birmingham, Birmingham, United Kingdom
| | - Amanda Kirkham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Iain Lyburn
- Cheltenham General Hospital, Cheltenham, United Kingdom
| | - Jenna Morgan
- University of Sheffield, Sheffield, United Kingdom
| | - Sangeetha Paramasivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | - Sarah Pirrie
- School of Cancer Sciences, Birmingham, United Kingdom
| | | | - Tracy Roberts
- University of Birmingham, Birmingham, United Kingdom
| | - Nisha Sharma
- Leeds Teaching Hospitals NHS Trust Research and Innovation Department, Leeds, United Kingdom
| | - Hilary Stobart
- Independent Cancer Patients' Voice, Cambridge, United Kingdom
| | | | | | - Matthew Wallis
- Department of Radiology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Dan Rea
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
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Ma YT, Kirkham A, Curbishley S, Rowe A, Blahova M, Mehrzad H, Karkhanis S, Punia P, James M, Rao AR, Stern N, Palmer DH, Hull D, Lowe F, Douglas-Pugh J, Bathurst C, Wilkhu M, Yap C, Adams DH. A randomised phase II clinical trial of low-dose cyclophosphamide and transarterial chemoembolization (TACE) with or without vaccination with dendritic cells (DC) pulsed with HepG2 lysate ex vivo in patients with hepatocellular carcinoma (HCC): The ImmunoTACE trial. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.4012] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4012 Background: A previous study by our group using autologous monocyte-derived DC pulsed ex vivo with HepG2 cell lysate showed some clinical benefit with evidence of antigen-specific T-cell responses in patients with advanced HCC. The current trial reports the activity of this vaccine in combination with TACE in patients with HCC. All patients also received low-dose cyclophosphamide to deplete regulatory T cells and thereby enhance vaccination. Methods: Patients with intermediate stage HCC (performance status 0-2, Child Pugh A/B7) were randomised 1:1 to TACE plus low-dose cyclophosphamide (Group 1) or TACE plus low-dose cyclophosphamide plus dendritic cell vaccination (Group 2). Cyclophosphamide was administered on Day 1 and 29 followed by TACE on Day 31 (+/- DC infusion), with further cyclophosphamide on Days 60, 90 and 120 (+/- additional DC infusions on Days 62, 92 and 122). The primary endpoint was progression free survival (PFS) by RECIST v1.1. Secondary endpoints included radiological response by RECIST v1.1, PFS and radiological response according to modified (m) RECIST, overall survival (OS), immune response and toxicity. Target recruitment was 48 evaluable patients (24 patients in each arm) to detect a 20% increase in PFS rate at 1 year (30% vs 50%) with a relaxed one-sided statistical significance level of 20% and 80% power using a logrank test. Results: Between March 2016 and October 2019, 55 patients from 3 UK centres were randomised of whom 48 were evaluable (24 each arm). Median PFS by RECIST criteria was significantly longer in Group 2 compared to Group 1 (18.6 vs 10.4 months: hazard ratio (HR) 0.43, 80% CI -∞-0.59; one-sided p = 0.02). Median PFS using mRECIST criteria showed a similar magnitude of benefit (18.6 vs 10.8 months: HR 0.48, 95% CI 0.22-1.02). Median OS was 25.7 months in Group 2 vs 21.5 months in Group 1 (HR 0.61, 95% CI 0.27-1.38). Group 2 showed a higher overall response rate (complete and partial response) by RECIST (54% vs 29%) and mRECIST (75% vs 54%) and a higher disease control rate (complete and partial response and stable disease) by RECIST (92% vs 67%) and mRECIST (88% vs 67%). Treatment with DC infusions was well tolerated; the most common adverse events were chills (30%), fatigue (22%) and nausea (22%), all of which were low grade. Immune response analyses are currently ongoing. Conclusions: The addition of tumour lysate pulsed DC infusions to treatment with TACE plus low-dose cyclophosphamide significantly increased PFS in patients with HCC. To the best of our knowledge, this is the first randomised study to demonstrate efficacy using DC in HCC. Further investigation of the role of DC infusions in the treatment of HCC are warranted but will need to take into account the current evolving immunotherapy landscape. Clinical trial information: 11889464.
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Affiliation(s)
- Yuk Ting Ma
- University of Birmingham, Birmingham, United Kingdom
| | - Amanda Kirkham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | | | - Anna Rowe
- University of Birmingham, Birmingham, United Kingdom
| | | | - Homoyon Mehrzad
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Salil Karkhanis
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Pankaj Punia
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Martin James
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Ankit Rohit Rao
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Nick Stern
- Aintree University Hospital, Liverpool, United Kingdom
| | | | - Diana Hull
- University of Birmingham, Birmingham, United Kingdom
| | - Faye Lowe
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Jessica Douglas-Pugh
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Camilla Bathurst
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Manpreet Wilkhu
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Christina Yap
- The Institute of Cancer Research, ICR-CTSU, Sutton, United Kingdom
| | - David H Adams
- University of Birmingham, Birmingham, United Kingdom
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8
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Phillips R, Cro S, Wheeler G, Bond S, Morris TP, Creanor S, Hewitt C, Love S, Lopes A, Schlackow I, Gamble C, MacLennan G, Habron C, Gordon AC, Vergis N, Li T, Qureshi R, Everett CC, Holmes J, Kirkham A, Peckitt C, Pirrie S, Ahmed N, Collett L, Cornelius V. Visualising harms in publications of randomised controlled trials: consensus and recommendations. BMJ 2022; 377:e068983. [PMID: 35577357 PMCID: PMC9108928 DOI: 10.1136/bmj-2021-068983] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To improve communication of harm in publications of randomised controlled trials via the development of recommendations for visually presenting harm outcomes. DESIGN Consensus study. SETTING 15 clinical trials units registered with the UK Clinical Research Collaboration, an academic population health department, Roche Products, and The BMJ. PARTICIPANTS Experts in clinical trials: 20 academic statisticians, one industry statistician, one academic health economist, one data graphics designer, and two clinicians. MAIN OUTCOME measures A methodological review of statistical methods identified visualisations along with those recommended by consensus group members. Consensus on visual recommendations was achieved (at least 60% of the available votes) over a series of three meetings with participants. The participants reviewed and critically appraised candidate visualisations against an agreed framework and voted on whether to endorse each visualisation. Scores marginally below this threshold (50-60%) were revisited for further discussions and votes retaken until consensus was reached. RESULTS 28 visualisations were considered, of which 10 are recommended for researchers to consider in publications of main research findings. The choice of visualisations to present will depend on outcome type (eg, binary, count, time-to-event, or continuous), and the scenario (eg, summarising multiple emerging events or one event of interest). A decision tree is presented to assist trialists in deciding which visualisations to use. Examples are provided of each endorsed visualisation, along with an example interpretation, potential limitations, and signposting to code for implementation across a range of standard statistical software. Clinician feedback was incorporated into the explanatory information provided in the recommendations to aid understanding and interpretation. CONCLUSIONS Visualisations provide a powerful tool to communicate harms in clinical trials, offering an alternative perspective to the traditional frequency tables. Increasing the use of visualisations for harm outcomes in clinical trial manuscripts and reports will provide clearer presentation of information and enable more informative interpretations. The limitations of each visualisation are discussed and examples of where their use would be inappropriate are given. Although the decision tree aids the choice of visualisation, the statistician and clinical trial team must ultimately decide the most appropriate visualisations for their data and objectives. Trialists should continue to examine crude numbers alongside visualisations to fully understand harm profiles.
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Affiliation(s)
- Rachel Phillips
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
- Pragmatic Clinical Trials Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Graham Wheeler
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tim P Morris
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
| | - Siobhan Creanor
- Exeter Clinical Trials Unit, University of Exeter, Exeter, UK
| | | | - Sharon Love
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
| | - Andre Lopes
- CRUK Cancer Trials Centre, University College London, London, UK
| | - Iryna Schlackow
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Graeme MacLennan
- Centre for Health Care Randomised Trials, University of Aberdeen, Aberdeen, UK
| | | | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Nikhil Vergis
- Imperial College London and Imperial NHS Trust, London, UK
| | - Tianjing Li
- Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Riaz Qureshi
- Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Colin C Everett
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jane Holmes
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amanda Kirkham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Clare Peckitt
- Royal Marsden Clinical Trials Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Sarah Pirrie
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Norin Ahmed
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Laura Collett
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
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9
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McIntosh SA, Coles CE, Conefrey C, Dodwell D, Elder K, Foster J, Gaunt C, Kirkham A, Lyburn I, Morgan J, Paramasivan S, Pinder S, Pirrie S, Potter S, Roberts T, Sharma N, Stobart H, Southgate E, Taylor-Phillips S, Wallis M, Rea D. Abstract OT1-06-02: SMALL - Open surgery versus minimally invasive vacuum-assisted excision for small screen detected breast cancer: A phase 3 randomised trial. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-ot1-06-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background:. Mammographic screening programmes have been shown to reduce breast cancer mortality. However, they detect many small tumours with favourable biological features which may not progress during a woman’s lifetime. These are treated with standard surgery and adjuvant therapies, which have associated morbidities. Thus, there is a need to reduce overtreatment of good prognosis tumours found by screening. Minimally invasive treatment approaches have been described but there is no prospective randomised evidence to support their routine use. Vacuum-assisted excision (VAE) is in widespread use for management of benign lesions and lesions of uncertain malignant potential. SMALL (ISRCTN 12240119) is designed to determine the feasibility of using this approach for treatment of small invasive tumours detected within the UK NHS Breast Screening Programme (BSP). Methods:. SMALL is a phase III multicentre randomised trial comparing standard surgery with VAE for screen-detected good prognosis breast cancers. The main eligibility criteria are age ≥47 years, screen-detected unifocal grade 1 tumours with maximum diameter 15mm, which are strongly ER/PR+ve and HER2-ve, with negative clinical/radiological axillary staging. Patients are randomised 2:1 in favour of VAE or surgery; with no axillary surgery in the VAE arm. Completeness of excision is assessed radiologically, and if excision is incomplete, patients undergo open surgery. Adjuvant radiotherapy and endocrine therapy are mandated in the VAE arm but may be omitted following surgery. Co-primary end-points are:1.Non-inferiority comparison of the requirement for a second procedure following excision2.Single arm analysis of local recurrence (LR) at 5 years following VAE. Recruitment of 800 patients over 4 years will permit demonstration of 10% non-inferiority of VAE for requirement of a second procedure. This ensures sufficient patients for single arm analysis of LR rates, where expected LR free survival is 99% at 5 years, with an undesirable survival probability after VAE of 97%. To ensure that the trial as a whole only has 5% alpha, the significance level for each co-primary outcome is set at 2.5% with 90% power. The Data Monitoring Committee will monitor LR events to ensure these do not exceed 3% per year. Secondary outcome measures include time to ipsilateral recurrence, overall survival, complications, quality of life and health economic analysis. A QuinteT Recruitment Intervention (QRI) is integrated throughout SMALL to optimise recruitment and informed consent. Recruitment challenges are identified by analysing recruiter/patient interviews and audio-recordings of trial discussions, and by review of screening, eligibility and recruitment data and study documentation. Solutions to address these are developed collaboratively, including individual/group recruiter feedback and recruitment tips documents. Results:. SMALL opened in December 2019, but recruitment halted in 2020 due to suspension of the NHS BSP for 5 months due to COVID-19. As of 1st July 2021, 55 patients had been approached in 10 centres, with 33 patients randomised (randomisation rate 60%). A further 23 centres are in set-up, with 8 suspended due to the pandemic. Drawing from preliminary QRI findings and insights from patient representatives, a recruitment tips document has been circulated (on introducing and discussing SMALL, providing balanced information. on treatment options and explaining randomisation). individual recruiter feedback has commenced, with wider feedback planned shortly. Conclusion:. Despite pandemic-related challenges, SMALL has an excellent recruitment rate to date and is expected to have a global impact on treatment of breast cancer within mammographic screening programmes. SMALL is funded by the UK NIHR HTA programme, award 17/42/32
Citation Format: Stuart A McIntosh, Charlotte E Coles, Carmel Conefrey, David Dodwell, Kenneth Elder, Jessica Foster, Claire Gaunt, Amanda Kirkham, Iain Lyburn, Jenna Morgan, Sangeetha Paramasivan, Sarah Pinder, Sarah Pirrie, Shelley Potter, Tracy Roberts, Nisha Sharma, Hilary Stobart, Elizabeth Southgate, Sian Taylor-Phillips, Matthew Wallis, Daniel Rea. SMALL - Open surgery versus minimally invasive vacuum-assisted excision for small screen detected breast cancer: A phase 3 randomised trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr OT1-06-02.
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Affiliation(s)
| | | | | | | | | | | | - Claire Gaunt
- University of Birmingham, Birmingham, United Kingdom
| | | | - Iain Lyburn
- Cheltenham General Hospital, Cheltenham, United Kingdom
| | - Jenna Morgan
- University of Sheffield, Sheffield, United Kingdom
| | | | | | - Sarah Pirrie
- University of Birmingham, Birmingham, United Kingdom
| | | | - Tracy Roberts
- University of Birmingham, Birmingham, United Kingdom
| | - Nisha Sharma
- St James's University Hospital, Leeds, United Kingdom
| | - Hilary Stobart
- Independent Cancer Patients' Voice, Cambridge, United Kingdom
| | | | | | | | - Daniel Rea
- University of Birmingham, Birmingham, United Kingdom
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10
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Norris J, Allen C, Ghei M, Kasivisvanathan V, Kirkham A, Oldroyd R, Whitaker H, Kelly D, Emberton M. Patient perspectives of multiparametric magnetic resonance imaging-directed prostate cancer diagnosis: A prospective systematic mixed-methods study (the PACT study). EUR UROL SUPPL 2021. [DOI: 10.1016/s2666-1683(21)02737-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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11
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Schwartz CL, Edwards K, Gamble W, Kirkham A, Lacy P, Lewis P, McDonagh STJ, Peers C, Sheppard JP, Swales P, Howarth J, Williams B. Validation of the Kinetik Blood Pressure Monitor-Series 1 for use in adults at home and in clinical settings, according to the 2002 European Society of Hypertension International Protocol on the validation of blood pressure devices. J Hum Hypertens 2021; 35:1046-1050. [PMID: 33223524 DOI: 10.1038/s41371-020-00445-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 07/21/2020] [Accepted: 11/03/2020] [Indexed: 02/03/2023]
Abstract
The aim of this study was to assess the blood pressure (BP) measurement accuracy of the Kinetik Blood Pressure Monitor-Series 1 (BPM-1) for use in home or clinical settings according to the 2002 European Society of Hypertension International Protocol (ESH-IP). Forty-two participants were recruited to fulfil the required number of systolic and diastolic BP measurements according to the ESH-IP. Nine sequential same-arm BP readings were measured and analysed for each participant using the test device and observer mercury standard readings according to the 2002 ESH-IP. Forty one participants were used to obtain 33 sets of systolic and diastolic BP readings and were included in the analysis. Mean difference between the device measurements and the observer (mercury standard) measurements was 1.1 ± 7.2/1.1 ± 6.8 mmHg (mean ± standard deviation; systolic/diastolic). The number of systolic BP differences between the test and observer measurements that fell within 5, 10 and 15 mmHg was 65, 86 and 92. For diastolic readings, the number of test-observer measurement differences within 5, 10 and 15 mmHg was 77, 91 and 94. The number of participants with at least two out of three differences within 5 mmHg was 28 for systolic and 40 for diastolic BP readings. Three participants had no differences between the test and observer measurements within 5 mmHg in both the systolic and diastolic measurement categories. The Kinetik BPM-1 device fulfilled the requirements of the ESH-IP validation procedure and can be recommended for clinical use and self-measurement within the home.
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Affiliation(s)
- C L Schwartz
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
| | - K Edwards
- University Hospitals of Leicester, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - W Gamble
- University Hospitals of Leicester, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - A Kirkham
- University Hospitals of Leicester, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - P Lacy
- Institute of Cardiovascular Sciences, NIHR UCL Hospitals Biomedical Research Centre, University College London, 170 Tottenham Court Road, London, W1T 7HA, UK
| | - P Lewis
- Stockport NHS Foundation Trust, Stepping Hill Hospital, Stockport, SK2 7JE, UK
| | - S T J McDonagh
- Primary Care Research Group, University of Exeter Medical School, College of Medicine and Health, Smeall Building, St Luke's Campus, Exeter, UK
| | - C Peers
- University Hospitals of Leicester, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - J P Sheppard
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK.
| | - P Swales
- University Hospitals of Leicester, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - J Howarth
- British and Irish Hypertension Society, Leicester, UK
| | - B Williams
- Institute of Cardiovascular Sciences, NIHR UCL Hospitals Biomedical Research Centre, University College London, 170 Tottenham Court Road, London, W1T 7HA, UK
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12
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Satish P, Freeman A, Kelly D, Kirkham A, Orczyk C, Simpson B, Giganti F, Whitaker H, Emberton M, Norris J. Prostate cancer topography and tumour conspicuity on multiparametric magnetic resonance imaging: A systematic review and meta-analysis. Eur Urol 2021. [DOI: 10.1016/s0302-2838(21)01283-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Stavrinides V, Norris J, Bott S, Brown L, Burns-Cox N, Dudderidge T, El-Shater Bosaily A, Frangou E, Freeman A, Ghei M, Henderson A, Hindley R, Kaplan R, Kirkham A, Oldroyd R, Parker C, Persad R, Punwani S, Rosario D, Shergill I, Carmona L, Winkler M, Whitaker H, Ahmed H, Emberton M. MRI index lesions in the cancerous prostate: How do they differ from false positive phenotypes? Lessons from the PROMIS study. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)33748-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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14
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Norris J, Simpson B, Parry M, Allen C, Ball R, Freeman A, Kelly D, Kim H, Kirkham A, You S, Kasivisvanathan V, Whitaker H, Emberton M. mpMRI-visible prostate cancer is enriched with genomic hallmarks of poor prognosis: A bioinformatic analysis. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)33723-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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15
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Norris J, Carmona Echeverria L, Bott S, Brown L, Burns-Cox N, Dudderidge T, El-Shater Bosaily A, Frangou E, Freeman A, Ghei M, Henderson A, Hindley R, Kaplan R, Kirkham A, Oldroyd R, Parker C, Persad R, Punwani S, Rosario D, Shergill I, Stavrinides V, Winkler M, Whitaker H, Ahmed H, Emberton M. Which prostate cancers are overlooked by mpMRI? An analysis from PROMIS. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)32877-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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16
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Kong A, Good J, Kirkham A, Savage J, Mant R, Llewellyn L, Parish J, Spruce R, Forster M, Schipani S, Harrington K, Sacco J, Murray P, Middleton G, Yap C, Mehanna H. Phase I trial of WEE1 inhibition with chemotherapy and radiotherapy as adjuvant treatment, and a window of opportunity trial with cisplatin in patients with head and neck cancer: the WISTERIA trial protocol. BMJ Open 2020; 10:e033009. [PMID: 32184305 PMCID: PMC7076237 DOI: 10.1136/bmjopen-2019-033009] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 01/15/2020] [Accepted: 01/30/2020] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Patients with head and neck squamous cell carcinoma with locally advanced disease often require multimodality treatment with surgery, radiotherapy and/or chemotherapy. Adjuvant radiotherapy with concurrent chemotherapy is offered to patients with high-risk pathological features postsurgery. While cure rates are improved, overall survival remains suboptimal and treatment has a significant negative impact on quality of life.Cell cycle checkpoint kinase inhibition is a promising method to selectively potentiate the therapeutic effects of chemoradiation. Our hypothesis is that combining chemoradiation with a WEE1 inhibitor will affect the biological response to DNA damage caused by cisplatin and radiation, thereby enhancing clinical outcomes, without increased toxicity. This trial explores the associated effect of WEE1 kinase inhibitor adavosertib (AZD1775). METHODS AND ANALYSIS This phase I dose-finding, open-label, multicentre trial aims to determine the highest safe dose of AZD1775 in combination with cisplatin chemotherapy preoperatively (group A) as a window of opportunity trial, and in combination with postoperative cisplatin-based chemoradiation (group B).Modified time-to-event continual reassessment method will determine the recommended dose, recruiting up to 21 patients per group. Primary outcomes are recommended doses with predefined target dose-limiting toxicity probabilities of 25% monitored up to 42 days (group A), and 30% monitored up to 12 weeks (group B). Secondary outcomes are disease-free survival times (groups A and B). Exploratory objectives are evaluation of pharmacodynamic (PD) effects, identification and correlation of potential biomarkers with PD markers of DNA damage, determine rate of resection status and surgical complications for group A; and quality of life in group B. ETHICS AND DISSEMINATION Research Ethics Committee, Edgbaston, West Midlands (REC reference 16/WM/0501) initial approval received on 18/01/2017. Results will be disseminated via peer-reviewed publication and presentation at international conferences. TRIAL REGISTRATION NUMBER ISRCTN76291951 and NCT03028766.
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Affiliation(s)
- Anthony Kong
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - James Good
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Amanda Kirkham
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Joshua Savage
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Rhys Mant
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - Joanna Parish
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Rachel Spruce
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - Stefano Schipani
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow, Glasgow, UK
| | | | - Joseph Sacco
- Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, Wirral, UK
| | | | - Gary Middleton
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Hisham Mehanna
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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Kirkham A, Xu L, Wang H, Chow K, Pagano JJ, White J, Haykowsky MJ, Dyck JR, Ezekowitz JA, Oudit GY, Mackey JR, Thompson RB, Pituskin E, Paterson I. Abstract P1-03-07: Breast cancer diagnosis is associated with relative left ventricular hypertrophy. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p1-03-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Cardiac dysfunction is a major concern for patients with breast cancer (BC) receiving adjuvant therapy. Retrospective, cross-sectional echocardiographic data suggests that patients with cancer have reduced myocardial strain prior to cancer therapy exposure. Cardiac magnetic resonance (CMR) is the gold standard imaging modality for cardiac structure and function and can also evaluate myocardial micro-architecture with T1 mapping. We hypothesized that treatment naïve patients with early-stage BC (ESBC) have abnormal myocardial tissue characteristics on CMR.
Methods: Women with newly diagnosed ESBC were prospectively recruited for CMR prior to cancer drug treatment. Those with hypertension, diabetes mellitus or prior cancer treatments were excluded. Age and sex matched healthy controls were identified from a prior prospective study. All participants underwent a non-contrast CMR scan on a 1.5T magnet. Image acquisition included cines for cardiac structure and function as well as T1 mapping using saturation recovery single-shot acquisitions. Global longitudinal strain (GLS) was derived from cine images. Demographics and imaging metrics for healthy controls and patients were compared using two-sample t-test.
Results: 106 patients with ESBC, mean age 51±9, were included along with 55 matched healthy controls. Body mass index and systolic blood pressure were similar between groups, however resting heart rate was elevated in patients compared to controls, 77±11 vs 67±11 /min respectively, p<0.001 (Table 1). On CMR there was no difference in left ventricular volume or ejection fraction however global longitudinal strain was higher in patients compared to controls, -20.9±2.3 vs -19.9±3.7%, p=0.04 (Table 2). Left ventricular mass was higher compared to controls, 52±6 and 47±6 g/m2 respectively, p<0.001. However myocardial T1 was similar between groups, T1=1198±27ms for controls vs 1206±46ms for patients, p=0.42.
Conclusions: The cardiac phenotype of patients with ESBC is characterized by relative left ventricular hypertrophy with normal myocardial tissue. Further understanding of the mechanisms involved may provide insight into the cardiovascular risk associated with BC diagnosis.
Table 1.Demographics Healthy Controls (n=55)Breast Cancer (n=106)P valueAge, years (SD)52(14)51(9)0.49Body mass index, kg/m2 (SD)26(5)27(6)0.38Hypertension, number00NADiabetes Mellitus, number00NAReceptor status, number (%) NAER/PRNA92(87%) HER2NA74(70%) Triple negativeNA2(2%) Stage, number (%) NA1NA43(42%) 2NA41(38%) 3NA23(20%) Systolic blood pressure, mmHg (SD)127(15)124(13)0.19Heart rate, /min (SD)67(11)77(11)<0.001SD=standard deviation, NA=not applicable
Table 2.Cardiac Magnetic Resonance Healthy Controls (n=55)Breast Cancer (n=106)P valueLVEF, % (SD)62(4)62(5)0.91Indexed LVEDV, ml/m2 (SD)69(9)72(14)0.18Indexed LV mass, g/m2 (SD)47(6)52(6)<0.001LV mass/LVEDV (SD)0.69(0.08)0.74(0.13)0.002Indexed left atrial volume, ml/m2 (SD)40(9)37(10)0.21Global longitudinal strain, % (SD)-19.9(3.7)-20.9(2.3)0.04Myocardial T1, ms (SD)1198(27)1206(46)0.42SD=standard deviation, LVEF=left ventricular ejection fraction, LVEDV=left ventricular end-diastolic volume, LV=left ventricular
Citation Format: Kirkham A, Xu L, Wang H, Chow K, Pagano JJ, White J, Haykowsky MJ, Dyck JR, Ezekowitz JA, Oudit GY, Mackey JR, Thompson RB, Pituskin E, Paterson I. Breast cancer diagnosis is associated with relative left ventricular hypertrophy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-03-07.
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Affiliation(s)
- A Kirkham
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - L Xu
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - H Wang
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - K Chow
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - JJ Pagano
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - J White
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - MJ Haykowsky
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - JR Dyck
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - JA Ezekowitz
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - GY Oudit
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - JR Mackey
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - RB Thompson
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - E Pituskin
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
| | - I Paterson
- University of Alberta, Edmonton, AB, Canada; University of Calgary, Calgary, AB, Canada; The University of Texas Arlington, Arlington, TX
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Laing RW, Mergental H, Yap C, Kirkham A, Whilku M, Barton D, Curbishley S, Boteon YL, Neil DA, Hübscher SG, Perera MTPR, Muiesan P, Isaac J, Roberts KJ, Cilliers H, Afford SC, Mirza DF. Viability testing and transplantation of marginal livers (VITTAL) using normothermic machine perfusion: study protocol for an open-label, non-randomised, prospective, single-arm trial. BMJ Open 2017; 7:e017733. [PMID: 29183928 PMCID: PMC5719273 DOI: 10.1136/bmjopen-2017-017733] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The use of marginal or extended criteria donor livers is increasing. These organs carry a greater risk of initial dysfunction and early failure, as well as inferior long-term outcomes. As such, many are rejected due to a perceived risk of use and use varies widely between centres. Ex situ normothermic machine perfusion of the liver (NMP-L) may enable the safe transplantation of organs that meet defined objective criteria denoting their high-risk status and are currently being declined for use by all the UK transplant centres. METHODS AND ANALYSIS Viability testing and transplantation of marginal livers is an open-label, non-randomised, prospective, single-arm trial designed to determine whether currently unused donor livers can be salvaged and safely transplanted with equivalent outcomes in terms of patient survival. The procured rejected livers must meet predefined criteria that objectively denote their marginal condition. The liver is subjected to NMP-L following a period of static cold storage. Organs metabolising lactate to ≤2.5 mmol/L within 4 hours of the perfusion commencing in combination with two or more of the following parameters-bile production, metabolism of glucose, a hepatic arterial flow rate ≥150 mL/min and a portal venous flow rate ≥500 mL/min, a pH ≥7.30 and/or maintain a homogeneous perfusion-will be considered viable and transplanted into a suitable consented recipient. The coprimary outcome measures are the success rate of NMP-L to produce a transplantable organ and 90-day patient post-transplant survival. ETHICS AND DISSEMINATION The protocol was approved by the National Research Ethics Service (London-Dulwich Research Ethics Committee, 16/LO/1056), the Medicines and Healthcare Products Regulatory Agency and is endorsed by the National Health Service Blood and Transplant Research, Innovation and Novel Technologies Advisory Group. The findings of this trial will be disseminated through national and international presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT02740608; Pre-results.
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Affiliation(s)
- Richard W Laing
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Hynek Mergental
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Amanda Kirkham
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Manpreet Whilku
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Darren Barton
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Stuart Curbishley
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Yuri L Boteon
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Desley A Neil
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stefan G Hübscher
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - M Thamara P R Perera
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Paolo Muiesan
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - John Isaac
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith J Roberts
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hentie Cilliers
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon C Afford
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Darius F Mirza
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Arndtz K, Corrigan M, Rowe A, Kirkham A, Barton D, Fox RP, Llewellyn L, Athwal A, Wilkhu M, Chen YY, Weston C, Desai A, Adams DH, Hirschfield GM. Investigating the safety and activity of the use of BTT1023 (Timolumab), in the treatment of patients with primary sclerosing cholangitis (BUTEO): A single-arm, two-stage, open-label, multi-centre, phase II clinical trial protocol. BMJ Open 2017; 7:e015081. [PMID: 28674140 PMCID: PMC5734279 DOI: 10.1136/bmjopen-2016-015081] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/29/2017] [Accepted: 05/17/2017] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Primary sclerosing cholangitis (PSC) is a progressive inflammatory liver disease characterised by relentless liver fibrosis and a high unmet need for new therapies. Preventing fibrosis represents an important area of interest in the development of vital new drugs. Vascular adhesion protein-1 (VAP-1) drives inflammation in liver disease, and provision of an antibody against VAP-1 blunts fibrosis in murine models of liver injury. METHODS AND ANALYSIS BUTEO is a single-arm, two-stage, open-label, multi-centre, phase II clinical trial. Up to 59 patients will receive treatment with anti-VAP monoclonal antibody, BTT1023, over a 78-day treatment period. Adults with PSC and a serum alkaline phosphatase (ALP) of at least 1.5 times the upper limit of normal will be included. Our primary outcome measure is a reduction in ALP by >25% from baseline to Day 99. Secondary outcome measures include safety and tolerability, changes pre therapy/post therapy in circulating serum VAP-1 as well as imaging findings. The first patient participant was recruited on 08 September 2015. ETHICS AND DISSEMINATION This protocol has been approved by the Research Ethics Committee (REC, reference 14/EM/1272). The first REC approval date was 06 January 2015 with three subsequent approved amendments. This article refers to protocol V3.0, dated 16 March 2016. Results will be disseminated via peer-reviewed publication and presentation at international conferences. TRIAL REGISTRATION The trial is registered with the European Medicines agency (EudraCT: 2014-002393-37), the National Institute for Health Research (Portfolio ID: 18051) and ISRCTN: 11233255. The clinicaltrials.gov identifier is NCT02239211. Pre-results.
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Affiliation(s)
- Katherine Arndtz
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Margaret Corrigan
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Anna Rowe
- NIHR Birmingham Biomedical Research Centre, Clinical Trials Group (D3B Team), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Amanda Kirkham
- Department of Statistics, CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Darren Barton
- NIHR Birmingham Biomedical Research Centre, Clinical Trials Group (D3B Team), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Richard P Fox
- Department of Statistics, CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Laura Llewellyn
- Early Drug Development Team, CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Amrita Athwal
- NIHR Birmingham Biomedical Research Centre, Clinical Trials Group (D3B Team), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Manpreet Wilkhu
- NIHR Birmingham Biomedical Research Centre, Clinical Trials Group (D3B Team), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Yung-Yi Chen
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Chris Weston
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Amisha Desai
- Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - David H Adams
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Gideon M Hirschfield
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
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Abstract
Injection of the subcutaneous tissues of the penis for enlargement of penile girth has been practised for many years by laypeople and medical practitioners alike. However, with recognition of the complications, the practice has died out. We report a series of five patients who presented having injected foreign materials into the subcutaneous tissues of their penises, including paraffin and mineral oils. Our patients had a variable time course of presentation ranging from 1 day following injection to over 26 years. Self-injection of the subcutaneous tissues of the penis is an unusual presentation for a penile mass but should be considered as a differential diagnosis in patients with a long latent period to presentation or with characteristic magnetic resonance imaging and histological appearances.
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Affiliation(s)
- U Ahmed
- University College London Hospitals NHS Foundation Trust , UK
| | - A Freeman
- University College London Hospitals NHS Foundation Trust , UK
| | - A Kirkham
- University College London Hospitals NHS Foundation Trust , UK
| | - D J Ralph
- University College London Hospitals NHS Foundation Trust , UK
| | - S Minhas
- University College London Hospitals NHS Foundation Trust , UK
| | - A Muneer
- University College London Hospitals NHS Foundation Trust , UK
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Kirkham A. Enhancing Nurse Faculty Retention Through Quality Work Environments: A Photovoice Project. Nurs Econ 2016; 34:289-295. [PMID: 29975491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The literature is rich with evidence that a nurse's work environment impacts his or her experience of factors related to turnover intent. However, one area of inquiry that has received little attention is the work environment of nursing faculty. The aim of this study was to gain an understanding of participants' lived experiences related to work environment quality and it's link with retention; use the knowledge gained to construct a definition of quality work environments from a nursing faculty perspective; and formulate grassroots recommendations that can serve as a stimulant for change within organizations. To achieve these aims, a participatory action research method, photovoice, was employed. Using this framework, nursing faculty were empowered to collect data using photography and construct meaning and recommendations for change.
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Kanthabalan A, Abd-Alazeez M, Arya M, Allen C, Freeman A, Jameson C, Kirkham A, Mitra A, Payne H, Punwani S, Ramachandran N, Walkden M, Emberton M, Ahmed H. Transperineal Magnetic Resonance Imaging-targeted Biopsy versus Transperineal Template Prostate Mapping Biopsy in the Detection of Localised Radio-recurrent Prostate Cancer. Clin Oncol (R Coll Radiol) 2016; 28:568-76. [DOI: 10.1016/j.clon.2016.04.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 01/19/2016] [Accepted: 03/08/2016] [Indexed: 12/14/2022]
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Teare L, Myers J, Kirkham A, Tredoux T, Martin R, Boasman S, Wisbey A, Charlton C, Dziewulski P. Prevention and control of carbapenemase-producing organisms at a regional burns centre. J Hosp Infect 2016; 93:141-4. [PMID: 27105751 DOI: 10.1016/j.jhin.2016.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 03/05/2016] [Indexed: 10/22/2022]
Abstract
In many parts of the world, carbapenemase-producing organisms (CPOs) are endemic. The transfer of medical patients from such countries to the UK requires us to have control systems in place to avoid onward transmission. This report describes the experience of a regional burns centre challenged by its first four cases of CPO in two separate incidents. Key learning from our experience was the importance of CPOs being considered in empirical antibiotics for any patient from an endemic area. Using contact plates, we demonstrated high bacterial counts after cleaning and we describe a terminal cleaning strategy along with the importance of continuing staff engagement and education.
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Affiliation(s)
- L Teare
- St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK.
| | - J Myers
- St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK
| | - A Kirkham
- St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK
| | - T Tredoux
- St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK
| | - R Martin
- St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK
| | - S Boasman
- St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK
| | - A Wisbey
- St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK
| | - C Charlton
- St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK
| | - P Dziewulski
- St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK
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Latifoltojar A, Dikaios N, Ridout A, Moore C, Illing R, Kirkham A, Taylor S, Halligan S, Atkinson D, Allen C, Emberton M, Punwani S. Evolution of multi-parametric MRI quantitative parameters following transrectal ultrasound-guided biopsy of the prostate. Prostate Cancer Prostatic Dis 2015; 18:343-51. [PMID: 26195470 PMCID: PMC4763162 DOI: 10.1038/pcan.2015.33] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 02/10/2015] [Revised: 05/03/2015] [Accepted: 05/31/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND To determine the evolution of prostatic multi-parametric magnetic resonance imaging (mp-MRI) signal following transrectal ultrasound (TRUS)-guided biopsy. METHODS Local ethical permission and informed written consent was obtained from all the participants (n=14, aged 43-69, mean 64 years). Patients with a clinical suspicion of prostate cancer (PSA range 2.2-11.7, mean 6.2) and a negative (PIRAD 1-2/5) pre-biopsy mp-MRI (pre-contrast T1, T2, diffusion-weighted and dynamic-contrast-enhanced MRI) who underwent 10-core TRUS-guided biopsy were recruited for additional mp-MRI examinations performed at 1, 2 and 6 months post biopsy. We quantified mp-MRI peripheral zone (PZ) and transition zone (TZ) normalized T2 signal intensity (nT2-SI); T1 relaxation time (T10); diffusion-weighted MRI, apparent diffusion coefficient (ADC); dynamic contrast-enhanced MRI, maximum enhancement (ME); slope of enhancement (SoE) and area-under-the-contrast-enhancement-curve at 120 s (AUC120). Significant changes in mp-MRI parameters were identified by analysis of variance with Dunnett's post testing. RESULTS Diffuse signal changes were observed post-biopsy throughout the PZ. No significant signal change occurred following biopsy within the TZ. Left and right PZ mean nT2-SI (left PZ: 5.73, 5.16, 4.90 and 5.12; right PZ: 5.80, 5.10, 4.84 and 5.05 at pre-biopsy, 1, 2 and 6 months post biopsy, respectively) and mean T10 (left PZ: 1.02, 0.67, 0.78, 0.85; right PZ: 1.29, 0.64, 0.78, 0.87 at pre-biopsy, 1, 2 and 6 months post biopsy, respectively) were reduced significantly (P<0.05) from pre-biopsy values for up to 6 months post biopsy. Significant changes (P<0.05) of PZ-ME and AUC120 were observed at 1 month but resolved by 2 months post biopsy. PZ ADC did not change significantly following biopsy (P=0.23-1.0). There was no significant change of any TZ mp-MRI parameter at any time point following biopsy (P=0.1-1.0). CONCLUSIONS Significant PZ (but not TZ) T2 signal changes persist up to 6 months post biopsy, whereas PZ and TZ ADC is not significantly altered as early as 1 month post biopsy. Caution must be exercised when interpreting T1- and T2-weighted imaging early post biopsy, whereas ADC images are more likely to maintain clinical efficacy.
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Affiliation(s)
- A Latifoltojar
- Centre for Medical Imaging, University College London, London, UK
| | - N Dikaios
- Centre for Medical Imaging, University College London, London, UK
| | - A Ridout
- Department of Urology, University College London Hospital, London, UK
| | - C Moore
- Department of Urology, University College London Hospital, London, UK
| | - R Illing
- Department of Radiology, University College London Hospital, London, UK
| | - A Kirkham
- Department of Radiology, University College London Hospital, London, UK
| | - S Taylor
- Centre for Medical Imaging, University College London, London, UK
- Department of Radiology, University College London Hospital, London, UK
| | - S Halligan
- Centre for Medical Imaging, University College London, London, UK
- Department of Radiology, University College London Hospital, London, UK
| | - D Atkinson
- Centre for Medical Imaging, University College London, London, UK
| | - C Allen
- Department of Radiology, University College London Hospital, London, UK
| | - M Emberton
- Department of Urology, University College London Hospital, London, UK
| | - S Punwani
- Centre for Medical Imaging, University College London, London, UK
- Department of Radiology, University College London Hospital, London, UK
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25
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Orczyk C, Punwani S, Kirkham A, Ramachandran N, Walkden M, Freeman A, Jameson C, Shehada M, Moore C, Arya M, Emberton M, Ahmed H. [Not Available]. Prog Urol 2015; 25:829-30. [PMID: 26544420 DOI: 10.1016/j.purol.2015.08.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- C Orczyk
- University College London, Londres, Royaume-Uni
| | - S Punwani
- University College London, Londres, Royaume-Uni
| | - A Kirkham
- University College London, Londres, Royaume-Uni
| | | | - M Walkden
- University College London, Londres, Royaume-Uni
| | - A Freeman
- University College London, Londres, Royaume-Uni
| | - C Jameson
- University College London, Londres, Royaume-Uni
| | - M Shehada
- University College London, Londres, Royaume-Uni
| | - C Moore
- University College London, Londres, Royaume-Uni
| | - M Arya
- University College London, Londres, Royaume-Uni
| | - M Emberton
- University College London, Londres, Royaume-Uni
| | - H Ahmed
- University College London, Londres, Royaume-Uni
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Abd-Alazeez M, Ramachandran N, Dikaios N, Ahmed HU, Emberton M, Kirkham A, Arya M, Taylor S, Halligan S, Punwani S. Multiparametric MRI for detection of radiorecurrent prostate cancer: added value of apparent diffusion coefficient maps and dynamic contrast-enhanced images. Prostate Cancer Prostatic Dis 2015; 18:128-36. [PMID: 25644248 DOI: 10.1038/pcan.2014.55] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 11/16/2014] [Accepted: 12/10/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Multiparametric magnetic resonance imaging (mp-MRI) is increasingly advocated for prostate cancer detection. There are limited reports of its use in the setting of radiorecurrent disease. Our aim was to assess mp-MRI for detection of radiorecurrent prostate cancer and examine the added value of its functional sequences. METHODS Thirty-seven men with mean age of 69.7 (interquartile range, 66-74) with biochemical failure after external beam radiotherapy underwent mp-MRI (T2-weighted, high b-value, multi-b-value apparent diffusion coefficient (ADC) and dynamic contrast-enhanced (DCE) imaging); then transperineal systematic template prostate mapping (TPM) biopsy. Using a locked sequential read paradigm (with the sequence order above), two experienced radiologists independently reported mp-MRI studies using score 1-5. Radiologist scores were matched with TPM histopathology at the hemigland level (n=74). Accuracy statistics were derived for each reader. Interobserver agreement was evaluated using kappa statistics. RESULTS Receiver-operator characteristic area under curve (AUC) for readers 1 and 2 increased from 0.67 (95% confidence interval (CI), 0.55-0.80) to 0.80 (95% CI, 0.69-0.91) and from 0.67 (95% CI, 0.55-0.80) to 0.84 (95% CI, 0.76-0.93), respectively, between T2-weighted imaging alone and full mp-MRI reads. Addition of ADC maps and DCE imaging to the examination did not significantly improve AUC for either reader (P=0.08 and 0.47 after adding ADC, P=0.90 and 0.27 after adding DCE imaging) compared with T2+high b-value review. Inter-reader agreement increased from k=0.39 to k=0.65 between T2 and full mp-MRI review. CONCLUSIONS mp-MRI can detect radiorecurrent prostate cancer. The optimal examination included T2-weighted imaging and high b-value DWI; adding ADC maps and DCE imaging did not significantly improve the diagnostic accuracy.
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Affiliation(s)
- M Abd-Alazeez
- 1] Department of Urology, University College Hospital NHS Foundation Trust, London, UK [2] Department of Urology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - N Ramachandran
- Department of Radiology, University College London Hospital, London, UK
| | - N Dikaios
- 1] Department of Radiology, University College London Hospital, London, UK [2] Centre for Medical Imaging, University College London, London, UK
| | - H U Ahmed
- 1] Department of Urology, University College Hospital NHS Foundation Trust, London, UK [2] Division of Surgery and Interventional Science, University College London, London, UK
| | - M Emberton
- 1] Department of Urology, University College Hospital NHS Foundation Trust, London, UK [2] Division of Surgery and Interventional Science, University College London, London, UK
| | - A Kirkham
- Department of Radiology, University College London Hospital, London, UK
| | - M Arya
- 1] Department of Urology, University College Hospital NHS Foundation Trust, London, UK [2] Barts Cancer Institute, Queen Mary University of London, London, UK
| | - S Taylor
- 1] Department of Radiology, University College London Hospital, London, UK [2] Centre for Medical Imaging, University College London, London, UK
| | - S Halligan
- 1] Department of Radiology, University College London Hospital, London, UK [2] Centre for Medical Imaging, University College London, London, UK
| | - S Punwani
- 1] Department of Radiology, University College London Hospital, London, UK [2] Centre for Medical Imaging, University College London, London, UK
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El-Shater Bosaily A, Arya M, Punwani S, Emberton M, Kirkham A, Freeman A, Ahmed H. Re: Multiparametric Magnetic Resonance Imaging Guided Diagnostic Biopsy Detects Significant Prostate Cancer and could Reduce Unnecessary Biopsies and Over Detection: A Prospective Study. J Urol 2015; 193:735-6; discussion 736. [DOI: 10.1016/j.juro.2014.08.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2014] [Indexed: 11/16/2022]
Affiliation(s)
- A. El-Shater Bosaily
- Research Department of Urology, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Center for Medical Imaging, Division of Medicine, University College London, London, United Kingdom
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - M. Arya
- Research Department of Urology, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Center for Medical Imaging, Division of Medicine, University College London, London, United Kingdom
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - S. Punwani
- Research Department of Urology, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Center for Medical Imaging, Division of Medicine, University College London, London, United Kingdom
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - M. Emberton
- Research Department of Urology, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Center for Medical Imaging, Division of Medicine, University College London, London, United Kingdom
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - A. Kirkham
- Research Department of Urology, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Center for Medical Imaging, Division of Medicine, University College London, London, United Kingdom
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - A. Freeman
- Research Department of Urology, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Center for Medical Imaging, Division of Medicine, University College London, London, United Kingdom
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - H.U. Ahmed
- Research Department of Urology, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Center for Medical Imaging, Division of Medicine, University College London, London, United Kingdom
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Walters GI, Kirkham A, McGrath EE, Moore VC, Robertson AS, Burge PS. Twenty years of SHIELD: decreasing incidence of occupational asthma in the West Midlands, UK? Occup Environ Med 2015; 72:304-10. [PMID: 25608805 DOI: 10.1136/oemed-2014-102141] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Since 2000 a decline in the incidence of occupational asthma (OA) has been reported in the UK and Europe. We aimed to describe and account for trends in the incidence of OA in the West Midlands, UK using annual notification data from the SHIELD voluntary surveillance scheme over the period 1991-2011. METHODS All notifications to the SHIELD database between January 1991 and December 2011 were identified, along with patients' demographic data, occupations, causative agents and confirmatory tests. Annual notifications were scaled to give an annual count per million workers, giving a measure of incidence, and also standardised against those of bakers' asthma. Non-parametric analyses were undertaken between annual incidence and time (years) for common causative agents using (1) a negative binomial regression univariate model and (2) a logistic regression model calculating annual reporting ORs. A step-change analysis was used to examine time points at which there were marked reductions in incidence. RESULTS A decrease in annual incidence of OA was observed over the study period (incident rate ratio=0.945; 95% CI 0.933 to 0.957; p<0.0001), an effect that was lost after standardising for bakers' asthma. Decreases in incidence were seen for most common causative agents, with only cleaning product-related OA increasing over 21 years. Marked fall in incidence was seen in 2004 for isocyanates, and in 1995 for latex. Most notifications came from a regional specialist occupational lung disease unit, with notifications from other sites falling from 16 cases/million workers/annum in 1995 to 0 in 2004. CONCLUSIONS Reporter fatigue and increasing under-recognition of OA are both factors which contribute to the apparent fall in incidence of OA in the West Midlands. There is a future need for interventions that enable health professionals to identify potential cases of OA in the workplace and in healthcare settings.
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Affiliation(s)
- G I Walters
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, UK
| | - A Kirkham
- Public Health, Epidemiology and Biostatistics, University of Birmingham, Edgbaston, UK
| | - E E McGrath
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, UK
| | - V C Moore
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, UK
| | - A S Robertson
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, UK
| | - P S Burge
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, UK
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Riley RD, Ahmed I, Ensor J, Takwoingi Y, Kirkham A, Morris RK, Noordzij JP, Deeks JJ. Meta-analysis of test accuracy studies: an exploratory method for investigating the impact of missing thresholds. Syst Rev 2015; 4:12. [PMID: 25652323 PMCID: PMC4417327 DOI: 10.1186/2046-4053-4-12] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 12/30/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Primary studies examining the accuracy of a continuous test evaluate its sensitivity and specificity at one or more thresholds. Meta-analysts then usually perform a separate meta-analysis for each threshold. However, the number of studies available for each threshold is often very different, as primary studies are inconsistent in the thresholds reported. Furthermore, of concern is selective reporting bias, because primary studies may be less likely to report a threshold when it gives low sensitivity and/or specificity estimates. This may lead to biased meta-analysis results. We developed an exploratory method to examine the potential impact of missing thresholds on conclusions from a test accuracy meta-analysis. METHODS Our method identifies studies that contain missing thresholds bounded between a pair of higher and lower thresholds for which results are available. The bounded missing threshold results (two-by-two tables) are then imputed, by assuming a linear relationship between threshold value and each of logit-sensitivity and logit-specificity. The imputed results are then added to the meta-analysis, to ascertain if original conclusions are robust. The method is evaluated through simulation, and application made to 13 studies evaluating protein:creatinine ratio (PCR) for detecting proteinuria in pregnancy with 23 different thresholds, ranging from one to seven per study. RESULTS The simulation shows the imputation method leads to meta-analysis estimates with smaller mean-square error. In the PCR application, it provides 50 additional results for meta-analysis and their inclusion produces lower test accuracy results than originally identified. For example, at a PCR threshold of 0.16, the summary specificity is 0.80 when using the original data, but 0.66 when also including the imputed data. At a PCR threshold of 0.25, the summary sensitivity is reduced from 0.95 to 0.85 when additionally including the imputed data. CONCLUSIONS The imputation method is a practical tool for researchers (often non-statisticians) to explore the potential impact of missing threshold results on their meta-analysis conclusions. Software is available to implement the method. In the PCR example, it revealed threshold results are vulnerable to the missing data, and so stimulates the need for advanced statistical models or, preferably, individual patient data from primary studies.
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Affiliation(s)
- Richard D Riley
- Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire, ST5 5BG UK
| | - Ikhlaaq Ahmed
- MRC Hub for Trials Methodology Research, School of Health and Population Sciences, University of Birmingham, Public Health Building, Edgbaston, Birmingham, B15 2TT UK
| | - Joie Ensor
- School of Health and Population Sciences, University of Birmingham, Public Health Building, Edgbaston, Birmingham, B15 2TT UK
| | - Yemisi Takwoingi
- School of Health and Population Sciences, University of Birmingham, Public Health Building, Edgbaston, Birmingham, B15 2TT UK
| | - Amanda Kirkham
- School of Health and Population Sciences, University of Birmingham, Public Health Building, Edgbaston, Birmingham, B15 2TT UK
| | - R Katie Morris
- Research Section of Reproduction, Genes and Development; School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK ; Fetal Medicine Centre, Birmingham Women's Hospital NHS Foundation Trust, Birmingham, UK
| | - J Pieter Noordzij
- Department of Otolaryngology - Head & Neck Surgery, Boston Medical Center, Boston University - School of Medicine, Boston, MA USA
| | - Jonathan J Deeks
- School of Health and Population Sciences, University of Birmingham, Public Health Building, Edgbaston, Birmingham, B15 2TT UK
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Sima C, Lau B, Kirkham A, Taylor C, Camp P. EVIDENCE OF ISCHEMIC HEART DISEASE AMONG CHRONIC LUNG DISEASE PATIENTS ATTENDING A PULMONARY REHABILITATION PROGRAM. Can J Cardiol 2014. [DOI: 10.1016/j.cjca.2014.07.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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31
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Walters GI, Kirkham A, McGrath EE, Moore VC, Robertson AS, Burge PS. P205 21 years of SHIELD: decreasing incidence of Occupational Asthma in the West Midlands, UK? Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kanthabalan A, Abl-Azzeez M, Arya M, Freeman A, Allen C, Kirkham A, Punwani S, Emberton M, Ahmed H. 717 Transperineal MRI-targeted biopsy versus transperineal template prostate mapping biopsy in the detection of localised radio-recurrent prostate cancer. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/s1569-9056(13)61199-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
MRI of the penis is an expensive test that is not always superior to clinical examination or ultrasound. However, it shows many of the important structures, and in particular the combination of tumescence from intracavernosal alprostadil, and high-resolution T(2) sequences show the glans, corpora and the tunica albuginea well. In this paper we summarise the radiological anatomy and discuss the indications for MRI. For penile cancer, it may be useful in cases where the local stage is not apparent clinically. In priapism, it is an emerging technique for assessing corporal viability, and in fracture it can in most cases make the diagnosis and locate the injury. In some cases of penile fibrosis and Peyronie's disease, it may aid surgical planning, and in complex pelvic fracture may replace or augment conventional urethrography. It is an excellent investigation for the malfunctioning penile prosthesis.
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Affiliation(s)
- A Kirkham
- University College Hospital, 235 Euston Road, London, UK.
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Kirkham A, Haley J, Haile Y, Grout A, Kimpton C, Al-Marzouqi A, Gill P. High-throughput analysis using AmpFlSTR® Identifiler® with the Applied Biosystems 3500xl Genetic Analyser. Forensic Sci Int Genet 2013; 7:92-7. [DOI: 10.1016/j.fsigen.2012.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 07/02/2012] [Accepted: 07/07/2012] [Indexed: 11/30/2022]
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Robertson NL, Moore CM, Ambler G, Bott SRJ, Freeman A, Gambarota G, Jameson C, Mitra AV, Whitcher B, Winkler M, Kirkham A, Allen C, Emberton M. MAPPED study design: a 6 month randomised controlled study to evaluate the effect of dutasteride on prostate cancer volume using magnetic resonance imaging. Contemp Clin Trials 2012; 34:80-9. [PMID: 23085153 DOI: 10.1016/j.cct.2012.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 09/20/2012] [Accepted: 10/10/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the percentage change in volume of prostate cancer, as assessed by T2-weighted MRI, following exposure to dutasteride (Avodart) 0.5mg daily for six months. PATIENTS AND METHODS MRI in Primary Prostate cancer after Exposure to Dutasteride (MAPPED) is a double-blind, placebo-controlled trial, supported by GlaxoSmithKline (GSK). Men with prostate cancer suitable for active surveillance (low-intermediate risk prostate cancer on biopsy), and a visible lesion on T2-weighted MRI of at least 0.2 cc, were eligible for consideration. Forty-two men were randomised to 6 months of daily dutasteride 0.5mg or placebo. Multi-parametric MRI (mpMRI) scans were performed at baseline, 3 and 6 months. The percentage changes in cancer volume over time will be compared between the dutasteride and placebo groups. Planned analyses will examine the association between tumour volume and characteristics (perfusion and contrast washout) as seen on mpMRI, HistoScan ultrasound and biopsy histopathology in both groups. DISCUSSION MAPPED is the first randomised controlled trial to use mpMRI to look at the effect of dutasteride on the volume of prostate cancer. If dutasteride is shown to reduce the volume of prostate cancer, it might be considered as an adjunct for men on active surveillance. Analysis of the placebo arm will allow us to comment on the short-term natural variability of the MR appearance in men who are not receiving any treatment. CONCLUSION MAPPED will evaluate the short-term effect of dutasteride on prostate cancer volume, as assessed by mpMRI, in men undergoing active surveillance for low or intermediate risk prostate cancer. The study completed recruitment in January 2012.
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Affiliation(s)
- N L Robertson
- Division of Surgical & Interventional Science, University College London, UK.
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Camille B, Christophe B, Yvon B, Henri VC, Pierre M, Dominique T, Bataille S, Chondolu S, An T, Khan S, Rayamajhi S, Kim GH, Roh YW, Lee CH, Kang CM, Bansal R, Singh KN, Saxena S, Malhotra K, Van Laecke S, Nagler E, Van Biesen W, Jadoul M, Vanholder R, Cucchiari D, Cucchiari D, Angelini C, Mirani M, Arosio P, Graziani G, Badalamenti S, Girfoglio D, Allen D, Kirkham A, Johri N, Wheeler DC, Choong S, Moochhala S, Unwin R, Fabris A, Lupo A, Fantin F, Ferraro PM, Caletti C, Comellato G, Messa M, Gambaro G, Tanaka H, Tatsumoto N, Tsuneyoshi S, Daijo Y, Bacallao Mendez RA, Bacallao R, Crombet T, Davalos JM, Llerena B, Leyva C, Manalich R, Beltrami P, Ruggera L, Iannetti A, Iafrate M, Guttilla A, Zattoni F, Arancio M, Zattoni F, Beltrami P, Ruggera L, Guttilla A, Iannetti A, Zattoni F, Gigli F, Zattoni F. Electrolyte disorders / Nephrolithiasis. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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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Abd Alazeez M, Ahmed H, Moore C, Kirkham A, Freeman A, Emberton M. The Role of mp-MRI in the Detection of Prostate Cancer. Clin Oncol (R Coll Radiol) 2012. [DOI: 10.1016/j.clon.2011.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Punwani S, Emberton M, Walkden M, Sohaib A, Freeman A, Ahmed H, Allen C, Kirkham A. Prostatic cancer surveillance following whole-gland high-intensity focused ultrasound: comparison of MRI and prostate-specific antigen for detection of residual or recurrent disease. Br J Radiol 2012; 85:720-8. [PMID: 22253342 DOI: 10.1259/bjr/61380797] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE This retrospective study compares dynamic contrast-enhanced (DCE) MRI with the serial prostate-specific antigen (PSA) measurement for detection of residual disease following whole-gland high-intensity focused ultrasound (HIFU) therapy of prostate cancer. METHODS Patients in whom post-HIFU DCE-MRI was followed within 3 months by ultrasound-guided transrectal biopsy were selected from a local database. 26 patients met the study inclusion criteria. Serial PSA levels following HIFU and post-HIFU follow-up MRI were retrieved for each patient. Three radiologists unaware of other investigative results independently assessed post-HIFU MRI studies for the presence of cancer, scoring on a four-point scale (1, no disease; 2, probably no disease; 3, probably residual disease; and 4, residual disease). Sensitivity, specificity and receiver operating characteristic (ROC) analysis were performed for each reader, post-HIFU PSA nadir and pre-biopsy PSA level thresholds of >0.2 and >0.5 ng ml(-1). RESULTS The sensitivity of DCE-MRI for detection of residual disease for the three readers ranged between 73% and 87%, and the specificity between 73% and 82%. There was good agreement between readers (κ = 0.69-0.77). The sensitivity and specificity of PSA thresholds was 60-87% and 73-100%, respectively. The area under the ROC curve was greatest for pre-biopsy PSA (0.95). CONCLUSION DCE-MRI performed following whole-gland HIFU has similar sensitivity and specificity and ROC performance to serial PSA measurements for detection of residual or recurrent disease.
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Affiliation(s)
- S Punwani
- Department of Radiology, University College London Hospital, London, UK
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39
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Ahmed H, Cathcart P, McCartan N, Kirkham A, Allen C, Freeman A, Emberton M. 225 FOCAL SALVAGE THERAPY COMPARED TO WHOLE-GLAND SALVAGE: A FEASIBILITY STUDY. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/s1569-9056(11)60225-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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40
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Arumainayagam N, Ahmed H, Moore C, Freeman A, Sohaib A, Kirkham A, Allen C, Emberton M. 133 A NEGATIVE MULTI-PARAMETRIC MRI CAN RULE OUT UP TO 97% OF CLINICALLY SIGNIFICANT PROSTATE CANCER. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/s1569-9056(11)60136-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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41
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Sahu M, Ahmed H, Kumaar S, Arumainayagam N, Rogers K, Scott R, Kirkham A, Allen C, Freeman A, Emberton M. UP-2.160: Treating Unilateral Localised Prostate Cancer with Hemi-Ablation High Intensity Focused Ultrasound (HIFU): Results of a NCRN-Approved Phase II Focal Therapy Clinical Trial. Urology 2009. [DOI: 10.1016/j.urology.2009.07.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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42
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Sahu M, Ahmed H, Kumaar S, Arumainayagam N, Rogers K, Scott R, Kirkham A, Allen C, Freeman A, Emberton M. UP-2.161: Focal High Intensity Focused Ultrasound (HIFU) Therapy in the Treatment of Localised Prostate Cancer: Early Results of a Phase II Trial. Urology 2009. [DOI: 10.1016/j.urology.2009.07.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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43
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Arumainayagam N, Kumaar S, Ahmed H, Moore C, Sahu M, Payne H, Freeman A, Allen C, Kirkham A, Emberton M. MP-21.13: Accuracy of Multi-sequence Magnetic Resonance Imaging of Radio-recurrent Prostate Cancer. Urology 2009. [DOI: 10.1016/j.urology.2009.07.757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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44
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Gill P, Curran J, Neumann C, Kirkham A, Clayton T, Whitaker J, Lambert J. Interpretation of complex DNA profiles using empirical models and a method to measure their robustness. Forensic Sci Int Genet 2008; 2:91-103. [DOI: 10.1016/j.fsigen.2007.10.160] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 09/03/2007] [Accepted: 10/09/2007] [Indexed: 12/01/2022]
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45
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Rouse P, Shaw G, Calleary J, Ahmed H, Zacharakis E, Illing R, Kirkham A, Freeman A, Allen C, Emberton M. MP-11.19: Can dynamic contrast enhanced magnetic resonance imaging of the prostate reliably detect prostate cancer prior to TRUS biopsy? Urology 2007. [DOI: 10.1016/j.urology.2007.06.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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46
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Gill P, Kirkham A, Curran J. LoComatioN: a software tool for the analysis of low copy number DNA profiles. Forensic Sci Int 2006; 166:128-38. [PMID: 16759831 DOI: 10.1016/j.forsciint.2006.04.016] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Accepted: 04/11/2006] [Indexed: 11/26/2022]
Abstract
Previously, the interpretation of low copy number (LCN) STR profiles has been carried out using the biological or 'consensus' method-essentially, alleles are not reported, unless duplicated in separate PCR analyses [P. Gill, J. Whitaker, C. Flaxman, N. Brown, J. Buckleton, An investigation of the rigor of interpretation rules for STRs derived from less than 100 pg of DNA, Forens. Sci. Int. 112 (2000) 17-40]. The method is now widely used throughout Europe. Although a probabilistic theory was simultaneously introduced, its time-consuming complexity meant that it could not be easily applied in practice. The 'consensus' method is not as efficient as the probabilistic approach, as the former wastes information in DNA profiles. However, the theory was subsequently extended to allow for DNA mixtures and population substructure in a programmed solution by Curran et al. [J.M. Curran, P. Gill, M.R. Bill, Interpretation of repeat measurement DNA evidence allowing for multiple contributors and population substructure, Forens. Sci. Int. 148 (2005) 47-53]. In this paper, we describe an expert interpretation system (LoComatioN) which removes this computational burden, and enables application of the full probabilistic method. This is the first expert system that can be used to rapidly evaluate numerous alternative explanations in a likelihood ratio approach, greatly facilitating court evaluation of the evidence. This would not be possible with manual calculation. Finally, the Gill et al. and Curran et al. papers both rely on the ability of the user to specify two quantities: the probability of allelic drop-out, and the probability of allelic contamination ("drop-in"). In this paper, we offer some guidelines on how these quantities may be specified.
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Affiliation(s)
- Peter Gill
- Forensic Science Service, Trident Court, 2960 Solihull Parkway, Solihull B37 7YN, UK.
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Gill P, Kirkham A. Development of a simulation model to assess the impact of contamination in casework using STRs. J Forensic Sci 2004; 49:485-91. [PMID: 15171164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Because contamination is usually tube-specific, negative controls cannot give assurance that an associated batch of extracted casework material is contaminant-free. However, it is possible to use them to predict the level of overall (undetected) contamination that is processed by an operational DNA unit. A MATLAB-based program was used to combine results of negative controls with actual casework DNA profiles to assess the probability that laboratory contaminants will give rise to reportable profiles (along with their likelihood ratios). Using data from an operational DNA unit as an example, it was demonstrated that the risk is inextricably linked to guidelines used to interpret DNA profiles. We have demonstrated how computer-based models can predict the levels of contamination expected in the process and, in addition, how the process can be made more robust by changing reporting guidelines. There is a need to compare DNA profiles against staff and plasticware elimination databases in order to determine sources of contamination. The likeliest outcome of a contamination event is false exclusion.
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Affiliation(s)
- Peter Gill
- Forensic Science Service, Trident Court, Birmingham Business Park, 2960 Solihull Parkway, Solihull, B37 7YN, UK
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Pitsiu M, Wilmer A, Bodenham A, Breen D, Bach V, Bonde J, Kessler P, Albrecht S, Fisher G, Kirkham A. Pharmacokinetics of remifentanil and its major metabolite, remifentanil acid, in ICU patients with renal impairment †. Br J Anaesth 2004; 92:493-503. [PMID: 14766712 DOI: 10.1093/bja/aeh086] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [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: 11/14/2022] Open
Abstract
BACKGROUND The pharmacokinetics of remifentanil, an opioid analgesic metabolized by non-specific esterases, and its principal metabolite, remifentanil acid (RA), which is excreted via the kidneys, were assessed as part of an open-label safety study in intensive care unit (ICU) patients with varying degrees of renal impairment. METHODS Forty adult ICU patients with normal/mildly impaired renal function (creatinine clearance [CL(cr)] 62.9 (sd) 14.5 ml min(-1); n=10) or moderate/severe renal impairment (CL(cr) 14.7 (15.7) ml min(-1); n=30) were included. Remifentanil was infused for up to 72 h, at a starting rate of 6-9 microg kg(-1) h(-1) titrated to achieve a target sedation level, with additional propofol (0.5 mg kg(-1) h(-1)) if required. Intensive arterial sampling was performed for up to 72 h after infusion. Pharmacokinetic parameters obtained by simultaneous modelling of remifentanil and RA data were statistically compared between the two groups. RESULTS Remifentanil pharmacokinetics were not significantly affected by renal status. RA clearance in the moderate/severe group was reduced to about 25% that of the normal/mild group (41 (29) vs 176 (49) ml kg(-1) h(-1), P<0.0001). Metabolic ratio, a predictor of the ratio of RA to remifentanil concentrations at steady state, was approximately eight-fold higher in the moderate/severe group relative to the normal/mild group (116 (110) vs 15 (4), P<0.0001). Maximum RA levels approached 700 ng ml(-1) in the moderate/severe group. CONCLUSIONS Although RA accumulates in patients with moderate/severe renal impairment, pharmacokinetic modelling predicts that RA concentrations during a 9 microg kg(-1) h(-1) remifentanil infusion for up to 15 days would not exceed those reported in the present study, for which no associated prolongation of mu-opioid effects was observed.
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Affiliation(s)
- M Pitsiu
- Medeval Ltd, Skelton House, Manchester Science Park, Lloyd Street North, Manchester M15 6SH, UK.
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Karabinis A, Mandragos K, Stergiopoulos S, Komnos A, Soukup J, Speelberg B, Kirkham A. Remifentanil-based analgesia and sedation facilitates more rapid and predictable time to neurological assessments. Crit Care 2004; 8. [PMCID: PMC4099823 DOI: 10.1186/cc2703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - K Mandragos
- Red Cross General Hospital of Athens, Greece
| | | | - A Komnos
- Koutlibanio General Hospital of Larisa, Greece
| | - J Soukup
- Martin-Luther-Universitat, Halle, Germany
| | - B Speelberg
- St Elizabeth Ziekenhuis, Tilburg, The Netherlands
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