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Brown MRD, Knight M, Peters CJ, Maleki S, Motavalli A, Nedjat-Shokouhi B. Digital outpatient health solutions as a vehicle to improve healthcare sustainability-a United Kingdom focused policy and practice perspective. Front Digit Health 2023; 5:1242896. [PMID: 37829594 PMCID: PMC10566364 DOI: 10.3389/fdgth.2023.1242896] [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: 06/19/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
Introduction In the midst of a global climate emergency and with health care systems across the world facing extreme pressure, interest in digital approaches as a potential part-solution to these challenges has increased rapidly. The evidence base to support the role that digitalization can play in moving towards more sustainable models of healthcare is growing, as is the awareness of this key area of healthcare reform amongst policy makers, clinicians and the public. Method and Results In this policy and practice review we explore four domains of healthcare sustainability-environmental, economic, and patient and clinician, delineating the potential impact that digitally enabled healthcare can have on each area. Real-world examples are provided to illustrate the impact individual digital interventions can have on each pillar of sustainability and demonstrate the scale of the potential benefits which can be achieved. Discussion Digitally enabled healthcare solutions present an approach which offer numerous benefits, including environmental sustainability, economic benefits, and improved patient experience. There are also potential drawbacks such as the risk of digital exclusion and the need for integration with existing technology platforms. Overall, it is essential to strike a balance between the benefits and potential drawbacks of digital healthcare solutions to ensure that they are equitable, effective, and sustainable.
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Affiliation(s)
- Matthew R. D. Brown
- Medefer, London, United Kingdom
- The Royal Marsden Hospital NHS Trust, London, United Kingdom
| | - Matthew Knight
- Medefer, London, United Kingdom
- West Hertfordshire Teaching Hospitals NHS Trust, Watford, Hertfordshire, United Kingdom
| | - Christopher J. Peters
- Medefer, London, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Matei DE, Menon M, Alber DG, Smith AM, Nedjat-Shokouhi B, Fasano A, Magill L, Duhlin A, Bitoun S, Gleizes A, Hacein-Bey-Abina S, Manson JJ, Rosser EC, Klein N, Blair PA, Mauri C. Intestinal barrier dysfunction plays an integral role in arthritis pathology and can be targeted to ameliorate disease. Med (N Y) 2021; 2:864-883.e9. [PMID: 34296202 PMCID: PMC8280953 DOI: 10.1016/j.medj.2021.04.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/22/2021] [Accepted: 04/15/2021] [Indexed: 12/29/2022]
Abstract
Background Evidence suggests an important role for gut-microbiota dysbiosis in the development of rheumatoid arthritis (RA). The link between changes in gut bacteria and the development of joint inflammation is missing. Here, we address whether there are changes to the gut environment and how they contribute to arthritis pathogenesis. Methods We analyzed changes in markers of gut permeability, damage, and inflammation in peripheral blood and serum of RA patients. Serum, intestines, and lymphoid organs isolated from K/BxN mice with spontaneous arthritis or from wild-type, genetically modified interleukin (IL)-10R−/−or claudin-8−/−mice with induced arthritis were analyzed by immunofluorescence/histology, ELISA, and flow cytometry. Findings RA patients display increased levels of serum markers of gut permeability and damage and cellular gut-homing markers, both parameters positively correlating with disease severity. Arthritic mice display increased gut permeability from early stages of disease, as well as bacterial translocation, inflammatory gut damage, increases in interferon γ (IFNγ)+and decreases in IL-10+intestinal-infiltrating leukocyte frequency, and reduced intestinal epithelial IL-10R expression. Mechanistically, both arthritogenic bacteria and leukocytes are required to disrupt gut-barrier integrity. We show that exposing intestinal organoids to IFNγ reduces IL-10R expression by epithelial cells and that mice lacking epithelial IL-10R display increased intestinal permeability and exacerbated arthritis. Claudin-8−/−mice with constitutively increased gut permeability also develop worse joint disease. Treatment of mice with AT-1001, a molecule that prevents development of gut permeability, ameliorates arthritis. Conclusions We suggest that breakdown of gut-barrier integrity contributes to arthritis development and propose restoration of gut-barrier homeostasis as a new therapeutic approach for RA. Funding Funded by Versus Arthritis (21140 and 21257) and UKRI/MRC (MR/T000910/1). Serum gut-permeability markers LPB, LPS, and I-FABP are increased in RA Mice with arthritis have increased gut permeability and intestinal inflammation Both bacteria and leukocytes are needed to disrupt gut-barrier integrity Prevention of gut-barrier dysfunction in arthritis ameliorates joint inflammation
Rheumatoid arthritis is an autoimmune disorder characterized by chronic joint inflammation. Accumulating evidence suggests that changes in the composition of the bacteria residing in the gut could be responsible for joint inflammation. Currently, it is unclear how bacteria or their products instruct cells of the immune system to become harmful and induce arthritis. Researchers at University College London have shown that, in arthritis, there is profound damage to the gut lining, which fails to work properly as a barrier, as well as an accumulation in the gut of white blood cells that cause inflammation. The authors show that, in arthritis, bacteria cross the prohibited border of the intestinal lining and that repairing gut permeability defects with specific drugs inhibits joint inflammation.
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Affiliation(s)
- Diana E Matei
- Centre for Rheumatology, Division of Medicine and Division of Infection and Immunity and Transplantation, University College London, London WC1E 6JF, UK
| | - Madhvi Menon
- Centre for Rheumatology, Division of Medicine and Division of Infection and Immunity and Transplantation, University College London, London WC1E 6JF, UK.,Evergrande Center for Immunologic Diseases, Harvard Medical School, Boston, MA 02115, USA.,Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA.,Lydia Becker Institute of Immunology and Inflammation, Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester M13 9PL, UK
| | - Dagmar G Alber
- Infection, Immunity and Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Andrew M Smith
- Eastman Dental Institute, School of Life and Medical Sciences, UCL, London WC1X 8LD, UK
| | - Bahman Nedjat-Shokouhi
- Eastman Dental Institute, School of Life and Medical Sciences, UCL, London WC1X 8LD, UK.,Centre for Molecular Medicine, Division of Medicine, UCL, London WC1E 6BT, UK
| | - Alessio Fasano
- MassGeneral Hospital for Children, Boston, MA 02114, USA
| | - Laura Magill
- Centre for Rheumatology, Division of Medicine and Division of Infection and Immunity and Transplantation, University College London, London WC1E 6JF, UK
| | - Amanda Duhlin
- Centre for Rheumatology, Division of Medicine and Division of Infection and Immunity and Transplantation, University College London, London WC1E 6JF, UK
| | - Samuel Bitoun
- Rheumatology Department, Bicêtre Hospital AP-HP, Université Paris-Saclay and INSERM UMR 1184 IMVA 78 Avenue du Général Leclerc, 94270 Le Kremlin Bicêtre, France
| | - Aude Gleizes
- Université de Paris, CNRS, INSERM, UTCBS, Unité des Technologies Chimiques et Biologiques pour la Santé, 75006 Paris, France.,Clinical Immunology Laboratory, Groupe Hospitalier Universitaire Paris-Sud, Hôpital Kremlin-Bicêtre, Assistance Publique-Hôpitaux de Paris, 94270 Le-Kremlin-Bicêtre, France
| | - Salima Hacein-Bey-Abina
- Université de Paris, CNRS, INSERM, UTCBS, Unité des Technologies Chimiques et Biologiques pour la Santé, 75006 Paris, France.,Assistance Publique - Hôpitaux Paris Saclay, Clinical Immunology Laboratory, Hôpital Bicêtre, 94275 Le-Kremlin-Bicêtre, France
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospital, London NW1 2BU, UK
| | - Elizabeth C Rosser
- Centre for Rheumatology, Division of Medicine and Division of Infection and Immunity and Transplantation, University College London, London WC1E 6JF, UK.,Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCLH and GOSH, London WC1E 6JF, UK
| | | | - Nigel Klein
- Infection, Immunity and Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Paul A Blair
- Centre for Rheumatology, Division of Medicine and Division of Infection and Immunity and Transplantation, University College London, London WC1E 6JF, UK
| | - Claudia Mauri
- Centre for Rheumatology, Division of Medicine and Division of Infection and Immunity and Transplantation, University College London, London WC1E 6JF, UK
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Nedjat-Shokouhi B, Glynn M, Denton ERE, Greenfield SM. Provision of out-of-hours services for acute upper gastrointestinal bleeding in England: results of the 2014-2015 BSG/NHS England national survey. Frontline Gastroenterol 2017; 8:8-12. [PMID: 28839878 PMCID: PMC5369431 DOI: 10.1136/flgastro-2016-100706] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/14/2016] [Accepted: 06/27/2016] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There has been a drive to raise the standard of management of acute upper gastrointestinal bleeding (AUGIB) in the UK, including three previous audits, sponsored by the British Society of Gastroenterology (BSG). OBJECTIVE To review the results of the latest BSG/National Health Service (NHS) England national survey of endoscopy services in England between 2014 and 2015. METHOD All NHS hospitals accepting acute admissions in England (168) were invited to respond to the survey. RESULTS Overall, 142 hospitals (84%) returned data. 85% of hospitals used a validated risk assessment score at the time of patient's admission. While 80% of hospitals provided a 24/7 endoscopy service for unstable patients, and another 10% were in network to provide an acute service, only 60% performed an endoscopy within 24 hours for stable acute admissions or inpatients with AUGIB. 11% of hospitals operated an out-of-hours ad hoc rota. 43% felt that pressure from routine work affected their ability to offer a next-day oesophagogastroduodenoscopy service, while 20% of hospitals struggled to recruit endoscopists. 28% of units reported that the previous national audit performed in 2013 had a positive influence on service development. CONCLUSIONS This survey has revealed significant deficiencies in provision of services for patients with AUGIB in England, without a significant increase in number of hospitals providing an emergency AUGIB service since the last national audit in 2013.
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Affiliation(s)
| | - Michael Glynn
- Department of Medicine, Barts Health NHS Trust, London, UK
| | - Erika R E Denton
- Department of Radiology, University of East Anglia and Norfolk & Norwich University Hospital, Norwich, UK
| | - Simon M Greenfield
- East and North Hertfordshire NHS Trust, Chairman Clinical Services and Standards Committee to the BSG, Stevenage, Hertfordshire, UK
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O’Shea NR, Chew TS, Dunne J, Marnane R, Nedjat-Shokouhi B, Smith PJ, Bloom SL, Smith AM, Segal AW. Critical Role of the Disintegrin Metalloprotease ADAM-like Decysin-1 [ADAMDEC1] for Intestinal Immunity and Inflammation. J Crohns Colitis 2016; 10:1417-1427. [PMID: 27226416 PMCID: PMC5174729 DOI: 10.1093/ecco-jcc/jjw111] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS ADAM [A Disintegrin And Metalloproteinase] is a family of peptidase proteins which have diverse roles in tissue homeostasis and immunity. Here, we study ADAM-like DECysin-1 [ADAMDEC1] a unique member of the ADAM family. ADAMDEC1 expression is restricted to the macrophage/dendritic cell populations of the gastrointestinal tract and secondary lymphoid tissue. The biological function of ADAMDEC1 is unknown but it has been hypothesised to play a role in immunity. The identification of reduced ADAMDEC1 expression in Crohn's disease patients has provided evidence of a potential role in bowel inflammation. METHODS Adamdec1-/- mice were exposed to dextran sodium sulphate or infected orally with Citrobacter rodentium or Salmonella typhimurium. The clinical response was monitored. RESULTS The loss of Adamdec1 rendered mice more susceptible to the induction of bacterial and chemical induced colitis, as evidenced by increased neutrophil infiltration, greater IL-6 and IL-1β secretion, more weight loss and increased mortality. In the absence of Adamdec1, greater numbers of Citrobacter rodentium were found in the spleen, suggestive of a breakdown in mucosal immunity which resulted in bacteraemia. CONCLUSION In summary, ADAMDEC1 protects the bowel from chemical and bacterial insults, failure of which may predispose to Crohn's disease.
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Affiliation(s)
| | - Thean S. Chew
- Division of Medicine, University College London, London, UK
| | - Jenny Dunne
- Division of Medicine, University College London, London, UK
| | | | | | | | - Stuart L. Bloom
- Department of Gastroenterology, University College London Hospital, UK
| | - Andrew M. Smith
- Division of Medicine, University College London, London, UK,Microbial Diseases, Eastman Dental Institute, University College London, London, UK,*These authors contributed equally to this work
| | - Anthony W. Segal
- Division of Medicine, University College London, London, UK,*These authors contributed equally to this work
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Pamecha V, Nedjat-Shokouhi B, Gurusamy K, Glantzounis GK, Sharma D, Davidson BR. Prospective evaluation of two-stage hepatectomy combined with selective portal vein embolisation and systemic chemotherapy for patients with unresectable bilobar colorectal liver metastases. Dig Surg 2008; 25:387-93. [PMID: 19033722 DOI: 10.1159/000176063] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 04/27/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND Liver resection is contraindicated in patients with multiple bilobar colorectal liver metastases because of the small liver remnant. An alternative strategy which may be curative is a two-stage hepatectomy in which the cancer is resected from one lobe and regeneration allowed prior to contralateral lobe resection. OBJECTIVE To assess the feasibility, risks, and outcomes in a prospectively applied strategy for two-stage hepatectomy. METHODS Over a 6-year period, 14 of 280 patients undergoing liver resection for colorectal liver metastases (5%) were considered for two-stage hepatectomy. Surgery was combined with chemotherapy in all (n = 14) and portal vein embolisation (PVE) selectively (n = 5). Median follow-up was 43 months. RESULTS Both stages were completed in 11 of 14 patients (78%). There were no deaths. Post-operative complication rates were 0% (1st hepatectomy) and 27% (2nd hepatectomy). The 5-year survival after the second hepatectomy was 50%. The mean disease-free survival was 25 +/- 7.5 months. CONCLUSION Two-stage hepatectomy combined with systemic chemotherapy and PVE can produce long-term survival in patients with multiple bilobar colorectal liver metastases.
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Affiliation(s)
- V Pamecha
- Hepato-Pancreatico-Biliary and Liver Transplant Unit, University Department of Surgery, Royal Free Hospital, and Royal Free University College Medical School, University College London, London, UK
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