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Mary S, Conti-Ramsden F, Boder P, Parveen H, Setjiadi D, Fleminger J, Brockbank A, Graham D, Bramham K, Chappell LC, Delles C. Pregnancy-associated changes in urinary uromodulin excretion in chronic hypertension. J Nephrol 2024:10.1007/s40620-023-01830-6. [PMID: 38236469 DOI: 10.1007/s40620-023-01830-6] [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: 05/08/2023] [Accepted: 11/10/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Pregnancy involves major adaptations in renal haemodynamics, tubular, and endocrine functions. Hypertensive disorders of pregnancy are a leading cause of maternal mortality and morbidity. Uromodulin is a nephron-derived protein that is associated with hypertension and kidney diseases. Here we study the role of urinary uromodulin excretion in hypertensive pregnancy. METHODS Urinary uromodulin was measured by ELISA in 146 pregnant women with treated chronic hypertension (n = 118) and controls (n = 28). We studied non-pregnant and pregnant Wistar Kyoto and Stroke Prone Spontaneously Hypertensive rats (n = 8/strain), among which a group of pregnant Stroke-Prone Spontaneously Hypertensive rats was treated with either nifedipine (n = 7) or propranolol (n = 8). RESULTS In pregnant women, diagnosis of chronic hypertension, increased maternal body mass index, Black maternal ethnicity and elevated systolic blood pressure at the first antenatal visit were significantly associated with a lower urinary uromodulin-to-creatinine ratio. In rodents, pre-pregnancy urinary uromodulin excretion was twofold lower in Stroke-Prone Spontaneously Hypertensive rats than in Wistar Kyoto rats. During pregnancy, the urinary uromodulin excretion rate gradually decreased in Wistar Kyoto rats (a twofold decrease), whereas a 1.5-fold increase was observed in Stroke-Prone Spontaneously Hypertensive rats compared to pre-pregnancy levels. Changes in uromodulin were attributed by kidney injury in pregnant rats. Neither antihypertensive changed urinary uromodulin excretion rate in pregnant Stroke-Prone Spontaneously Hypertensive rats. CONCLUSIONS In summary, we demonstrate pregnancy-associated differences in urinary uromodulin: creatinine ratio and uromodulin excretion rate between chronic hypertensive and normotensive pregnancies. Further research is needed to fully understand uromodulin physiology in human pregnancy and establish uromodulin's potential as a biomarker for renal adaptation and renal function in pregnancy.
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Affiliation(s)
- Sheon Mary
- School of Cardiovascular and Metabolic Health, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| | - Fran Conti-Ramsden
- Department of Women and Children's Health, King's College London, London, UK
| | - Philipp Boder
- School of Cardiovascular and Metabolic Health, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Humaira Parveen
- School of Cardiovascular and Metabolic Health, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Dellaneira Setjiadi
- School of Cardiovascular and Metabolic Health, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Jessica Fleminger
- Department of Women and Children's Health, King's College London, London, UK
| | - Anna Brockbank
- Department of Women and Children's Health, King's College London, London, UK
| | - Delyth Graham
- School of Cardiovascular and Metabolic Health, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Kate Bramham
- Department of Women and Children's Health, King's College London, London, UK
| | | | - Christian Delles
- School of Cardiovascular and Metabolic Health, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
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Conti‐Ramsden F, Fleminger J, Lanoue J, Chappell LC, Battersby C. The contribution of hypertensive disorders of pregnancy to late preterm and term admissions to neonatal units in the UK 2012-2020 and opportunities to avoid admission: A population-based study using the National Neonatal Research Database. BJOG 2024; 131:88-98. [PMID: 37337344 PMCID: PMC10767760 DOI: 10.1111/1471-0528.17574] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 03/10/2023] [Revised: 05/22/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE To quantify maternal hypertensive disorder of pregnancy (HDP) prevalence in late preterm and term infants admitted to neonatal units (NNU) and assess opportunities to avoid admissions. DESIGN A retrospective population-based study using the National Neonatal Research Database. SETTING England and Wales. POPULATION Infants born ≥34 weeks' gestation admitted to NNU between 2012 and 2020. METHODS Outcomes in HDP infants are compared with non-HDP infants using regression models. MAIN OUTCOME MEASURES Hypertensive disorder of pregnancy, primary reason for admission, clinical diagnoses and resource use. RESULTS 16 059/136 220 (11.8%) of late preterm (34+0 to 36+6 weeks' gestation) and 14 885/284 646 (5.2%) of term (≥37 weeks' gestation) admitted infants were exposed to maternal HDP. The most common primary reasons for HDP infant admission were respiratory disease (28.3%), prematurity (22.7%) and hypoglycaemia (16.4%). HDP infants were more likely to be admitted with primary hypoglycaemia than were non-HDP infants (odds ratio [OR] 2.1, 95% confidence interval [CI] 2.0-2.2, P < 0.0001). 64.5% of HDP infants received i.v. dextrose. 35.7% received mechanical or non-invasive ventilation. 8260/30 944 (26.7%) of HDP infants received intervention for hypoglycaemia alone (i.v. dextrose) with no other major intervention (respiratory support, parenteral nutrition, central line, arterial line or blood transfusion). CONCLUSIONS The burden of maternal HDP on late preterm and term admissions to NNU is high, with hypoglycaemia and respiratory disease being the main drivers for admission. Over one in four were admitted solely for management of hypoglycaemia. Further research should determine whether maternal antihypertensive agent choice or postnatal pathways may reduce NNU admission.
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Affiliation(s)
| | - Jessica Fleminger
- Department of Women and Children's HealthKing's College LondonLondonUK
| | - Julia Lanoue
- Neonatal Medicine, School of Public Health, Faculty of MedicineImperial College LondonLondonUK
| | - Lucy C. Chappell
- Department of Women and Children's HealthKing's College LondonLondonUK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of MedicineImperial College LondonLondonUK
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Chappell LC, Brocklehurst P, Green M, Hardy P, Hunter R, Beardmore-Gray A, Bowler U, Brockbank A, Chiocchia V, Cox A, Duhig K, Fleminger J, Gill C, Greenland M, Hendy E, Kennedy A, Leeson P, Linsell L, McCarthy FP, O'Driscoll J, Placzek A, Poston L, Robson S, Rushby P, Sandall J, Scholtz L, Seed PT, Sparkes J, Stanbury K, Tohill S, Thilaganathan B, Townend J, Juszczak E, Marlow N, Shennan A. Planned delivery for pre-eclampsia between 34 and 37 weeks of gestation: the PHOENIX RCT. Health Technol Assess 2022:10.3310/CWWH0622. [PMID: 36547875 PMCID: PMC10068586 DOI: 10.3310/cwwh0622] [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] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND In women with late preterm pre-eclampsia (i.e. at 34+0 to 36+6 weeks' gestation), the optimal delivery time is unclear because limitation of maternal-fetal disease progression needs to be balanced against infant complications. The aim of this trial was to determine whether or not planned earlier initiation of delivery reduces maternal adverse outcomes without substantial worsening of perinatal or infant outcomes, compared with expectant management, in women with late preterm pre-eclampsia. METHODS We undertook an individually randomised, triple non-masked controlled trial in 46 maternity units across England and Wales, with an embedded health economic evaluation, comparing planned delivery and expectant management (usual care) in women with late preterm pre-eclampsia. The co-primary maternal outcome was a maternal morbidity composite or recorded systolic blood pressure of ≥ 160 mmHg (superiority hypothesis). The co-primary short-term perinatal outcome was a composite of perinatal deaths or neonatal unit admission (non-inferiority hypothesis). Analyses were by intention to treat, with an additional per-protocol analysis for the perinatal outcome. The primary 2-year infant neurodevelopmental outcome was measured using the PARCA-R (Parent Report of Children's Abilities-Revised) composite score. The planned sample size of the trial was 900 women; the trial is now completed. We undertook two linked substudies. RESULTS Between 29 September 2014 and 10 December 2018, 901 women were recruited; 450 women [448 women (two withdrew consent) and 471 infants] were allocated to planned delivery and 451 women (451 women and 475 infants) were allocated to expectant management. The incidence of the co-primary maternal outcome was significantly lower in the planned delivery group [289 (65%) women] than in the expectant management group [338 (75%) women] (adjusted relative risk 0.86, 95% confidence interval 0.79 to 0.94; p = 0.0005). The incidence of the co-primary perinatal outcome was significantly higher in the planned delivery group [196 (42%) infants] than in the expectant management group [159 (34%) infants] (adjusted relative risk 1.26, 95% confidence interval 1.08 to 1.47; p = 0.0034), but indicators of neonatal morbidity were similar in both groups. At 2-year follow-up, the mean PARCA-R scores were 89.5 points (standard deviation 18.2 points) for the planned delivery group (290 infants) and 91.9 points (standard deviation 18.4 points) for the expectant management group (256 infants), both within the normal developmental range (adjusted mean difference -2.4 points, 95% confidence interval -5.4 to 0.5 points; non-inferiority p = 0.147). Planned delivery was significantly cost-saving (-£2711, 95% confidence interval -£4840 to -£637) compared with expectant management. There were nine serious adverse events in the planned delivery group and 12 in the expectant management group. CONCLUSION In women with late preterm pre-eclampsia, planned delivery reduces short-term maternal morbidity compared with expectant management, with more neonatal unit admissions related to prematurity but no indicators of greater short-term neonatal morbidity (such as need for respiratory support). At 2-year follow-up, around 60% of parents reported follow-up scores. Average infant development was within the normal range for both groups; the small between-group mean difference in PARCA-R scores is unlikely to be clinically important. Planned delivery was significantly cost-saving to the health service. These findings should be discussed with women with late preterm pre-eclampsia to allow shared decision-making on timing of delivery. LIMITATIONS Limitations of the trial include the challenges of finding a perinatal outcome that adequately represented the potential risks of both groups and a maternal outcome that reflects the multiorgan manifestations of pre-eclampsia. The incidences of maternal and perinatal primary outcomes were higher than anticipated on the basis of previous studies, but this did not limit interpretation of the analysis. The trial was limited by a higher loss to follow-up rate than expected, meaning that the extent and direction of bias in outcomes (between responders and non-responders) is uncertain. A longer follow-up period (e.g. up to 5 years) would have enabled us to provide further evidence on long-term infant outcomes, but this runs the risk of greater attrition and increased expense. FUTURE WORK We identified a number of further questions that could be prioritised through a formal scoping process, including uncertainties around disease-modifying interventions, prognostic factors, longer-term follow-up, the perspectives of women and their families, meta-analysis with other studies, effect of a similar intervention in other health-care settings, and clinical effectiveness and cost-effectiveness of other related policies around neonatal unit admission in late preterm birth. TRIAL REGISTRATION The trial was prospectively registered as ISRCTN01879376. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in Health Technology Assessment. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lucy C Chappell
- School of Life Course Sciences, King's College London, London, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | | | - Ursula Bowler
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anna Brockbank
- School of Life Course Sciences, King's College London, London, UK
| | - Virginia Chiocchia
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alice Cox
- School of Life Course Sciences, King's College London, London, UK
| | - Kate Duhig
- School of Life Course Sciences, King's College London, London, UK
| | | | - Carolyn Gill
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melanie Greenland
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Eleanor Hendy
- School of Life Course Sciences, King's College London, London, UK
| | - Ann Kennedy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paul Leeson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Fergus P McCarthy
- Department of Obstetrics and Gynaecology, University of Cork, Cork, Ireland
| | - Jamie O'Driscoll
- School of Psychology and Life Sciences, Canterbury Christ Church University, Kent, UK
| | - Anna Placzek
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Lucilla Poston
- School of Life Course Sciences, King's College London, London, UK
| | - Stephen Robson
- Population Health Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Pauline Rushby
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane Sandall
- School of Life Course Sciences, King's College London, London, UK
| | - Laura Scholtz
- School of Life Course Sciences, King's College London, London, UK
| | - Paul T Seed
- School of Life Course Sciences, King's College London, London, UK
| | - Jenie Sparkes
- School of Life Course Sciences, King's College London, London, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sue Tohill
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Edmund Juszczak
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Neil Marlow
- Institute for Women's Health, University College London, London, UK
| | - Andrew Shennan
- School of Life Course Sciences, King's College London, London, UK
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Bremner L, Gill C, Seed PT, Conti-Ramsden F, Webster L, Fleminger J, Chappell LC, Shennan A, Bramham K. Rule-in and rule-out of pre-eclampsia using DELFIA Xpress PlGF 1-2-3 and sFlt-1: PlGF ratio. Pregnancy Hypertens 2022; 27:96-102. [PMID: 34979346 DOI: 10.1016/j.preghy.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/18/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The objective of this study was to explore and validate thresholds for Placental growth factor (PlGF) and soluble fms-like tyrosine-kinase 1 (s-Flt-1) (as s-Flt-1: PlGF ratio), to rule-in and rule-out disease in women with suspected pre-eclampsia, using DELFIA® Xpress PlGF1-2-3 and sFlt-1 assays. STUDY DESIGN 369 samples from women with suspected or confirmed pre-eclampsia were analysed from a prospective cohort study. MAIN OUTCOME MEASURES Serum PlGF and sFlt-1: PlGF were quantified using DELFIA® Xpress PlGF1-2-3 and DELFIA® Xpress sFlt-1 tests. Performances were evaluated at established and exploratory thresholds. Low PlGF concentration and sFlt-1: PlGF AUROC were compared. RESULTS PlGF 1-2-3 concentration thresholds were confirmed to have high performance for rule-in (<50 pg/ml) and rule-out (≥150 pg/ml) pre-eclampsia within seven days (20-33+6 Weeks <50 pg/ml: Negative predictive value (NPV) 90.7% (95% CI 83.9, 95.3); ≥150 pg/ml: NPV 94.8% (95% CI 88.4, 98.3)) and 28 days (20-33+6 Weeks <50 pg/ml: Negative predictive value (NPV) 83.9% (95% CI 76.0, 90.0); ≥150 pg/ml: NPV 92.8% (95% CI 85.7, 97.0)). Optimal sFlt-1: PlGF thresholds for rule-in were ≥ 70 before 34 weeks and ≥ 90 after 34 weeks, and <50 to rule-out pre-eclampsia. Low PlGF alone had comparable performance to sFlt-1: PlGF, but test performance for both was reduced in women with Kidney Disease. CONCLUSIONS DELFIA® Xpress PlGF1-2-3 and sFlt-1 assays for pre-eclampsia rule-in and rule-out have comparable performance to other established assays, and could be an alternative for clinical use. Performance was not enhanced by use of sFlt-1: PlGF ratio, suggesting that PlGF alone could provide a cheaper alternative to dual biomarker testing.
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Affiliation(s)
- Laura Bremner
- Department of Women and Children's Health, King's College London, London
| | - Carolyn Gill
- Department of Women and Children's Health, King's College London, London
| | - Paul T Seed
- Department of Women and Children's Health, King's College London, London
| | | | - Louise Webster
- Department of Women and Children's Health, King's College London, London
| | - Jessica Fleminger
- Department of Women and Children's Health, King's College London, London
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London; Guy's and St. Thomas' NHS Foundation Trust, London
| | - Andrew Shennan
- Department of Women and Children's Health, King's College London, London
| | - Kate Bramham
- Department of Women and Children's Health, King's College London, London; Department of Renal Medicine, King's College Hospital NHS Foundation Trust, London.
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Fleminger J, Duhig K, Seed PT, Brocklehurst P, Green M, Juszczak E, Marlow N, Shennan A, Chappell L. Factors influencing perinatal outcomes in women with preterm preeclampsia: A secondary analysis of the PHOENIX trial. Pregnancy Hypertens 2021; 26:91-93. [PMID: 34688088 DOI: 10.1016/j.preghy.2021.10.002] [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: 07/12/2021] [Revised: 09/16/2021] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
This secondary analysis of the PHOENIX trial (evaluating planned delivery against expectant management in late preterm preeclampsia) demonstrates that in women who started induction of labour, 63% of women delivered vaginally (56% at 34 weeks' gestation). Compared to expectant management, planned delivery was associated with higher rates of neonatal unit admission for prematurity (but lower proportions of small-for-gestational age infants); length of neonatal unit stay and neonatal morbidity (including respiratory support) were similar across both intervention groups at all gestational windows. Neonatal unit admission was increased by earlier gestation at delivery, development of severe preeclampsia, and being small-for-gestational age.
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Affiliation(s)
- Jessica Fleminger
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Kate Duhig
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Edmund Juszczak
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Neil Marlow
- ULC EGA Institute for Women's Health, University College London, London, UK
| | - Andrew Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Lucy Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
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Beardmore-Gray A, Seed P, Fleminger J, Shennan A, Groen H, Chappell L. P-069. Planned delivery or expectant management for the prevention of adverse pregnancy outcomes in pre-eclampsia: A meta-analysis of individual participant data. Pregnancy Hypertens 2021. [DOI: 10.1016/j.preghy.2021.07.104] [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: 11/16/2022]
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Fleminger J, Seed PT, Smith A, Juszczak E, Dixon PH, Chambers J, Dorling J, Williamson C, Thornton JG, Chappell LC. Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a secondary analysis of the PITCHES trial. BJOG 2020; 128:1066-1075. [PMID: 33063439 PMCID: PMC8246759 DOI: 10.1111/1471-0528.16567] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate whether a particular group of women with intrahepatic cholestasis of pregnancy (ICP), based on their presenting characteristics, would benefit from treatment with ursodeoxycholic acid (UDCA). DESIGN Secondary analysis of the PITCHES trial (ISRCTN91918806). SETTING United Kingdom. POPULATION OR SAMPLE 527 women with ICP. METHODS Subgroup analyses were performed to determine whether baseline bile acid concentrations or baseline itch scores moderated a woman's response to treatment with UDCA. MAIN OUTCOME MEASURES Bile acid concentration and itch score. RESULTS In women with baseline bile acid concentrations less than 40 μmol/l, treatment with UDCA resulted in increased post-randomisation bile acid concentrations (geometric mean ratio 1.19, 95% CI 1.00-1.41, P = 0.048). A test of interaction showed no significance (P = 0.647). A small, clinically insignificant difference was seen in itch response in women with a high baseline itch score (-6.0 mm, 95% CI -11.80 to -0.21, P = 0.042), with a test of interaction not showing significance (P = 0.640). Further subgroup analyses showed no significance. Across all women there was a weak relationship between bile acid concentrations and itch severity. CONCLUSIONS There was no subgroup of women with ICP in whom a beneficial effect of treatment with UDCA on bile acid concentration or itch score could be identified. This confirms that its routine use in women with this condition for improvement of bile acid concentration or itch score should be reconsidered. TWEETABLE ABSTRACT PITCHES: No group of women with ICP has been found in whom UDCA reduces bile acid concentrations or pruritus.
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Affiliation(s)
- J Fleminger
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - P T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - A Smith
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - E Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - P H Dixon
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | | | - J Dorling
- Division of Neonatal-Perinatal Medicine, IWK Health Centre, Halifax, NS, Canada
| | - C Williamson
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - J G Thornton
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - L C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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Jenkins PO, Roussakis AA, De Simoni S, Bourke N, Fleminger J, Cole J, Piccini P, Sharp D. Distinct dopaminergic abnormalities in traumatic brain injury and Parkinson's disease. J Neurol Neurosurg Psychiatry 2020; 91:631-637. [PMID: 32381639 DOI: 10.1136/jnnp-2019-321759] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 08/01/2019] [Revised: 12/05/2019] [Accepted: 01/09/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) and rapid eye movement sleep behavioural disorder (RBD) are risk factors for Parkinson's disease (PD). Dopaminergic abnormalities are often seen after TBI, but patients usually lack parkinsonian features. We test whether TBI, PD and RBD have distinct striatal dopamine abnormalities using dopamine transporter (DaT) imaging. METHODS 123I-ioflupane single-photon emission CT scans were used in a cross-sectional study to measure DaT levels in moderate/severe TBI, healthy controls, patients with early PD and RBD. Caudate and putamen DaT, putamen to caudate ratios and left-right symmetry of DaT were compared. RESULTS 108 participants (43 TBI, 26 PD, 8 RBD, 31 controls) were assessed. Patients with early PD scored significantly higher on the Unified Parkinson's Disease Rating Scale motor subscale than other groups. Patients with TBI and PD had reduced DaT levels in the caudate (12.2% and 18.7%, respectively) and putamen (9.0% and 42.6%, respectively) compared with controls. Patients with RBD had reduced DaT levels in the putamen (12.8%) but not in the caudate compared with controls. Patients with PD and TBI showed distinct patterns of DaT reduction, with patients with PD showing a lower putamen to caudate ratio. DaT asymmetry was greater in the PD group than other groups. CONCLUSIONS The results show that patients with early PD and TBI have distinct patterns of striatal dopamine abnormalities. Patients with early PD and moderate/severe TBI showed similar reductions in caudate DaT binding, but patients with PD showed a greater reduction in putamen DaT and a lower putamen to caudate ratio. The results suggest that parkinsonian motor signs are absent in these patients with TBI because of relatively intact putaminal dopamine levels.
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Affiliation(s)
- Peter Owen Jenkins
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College, London, United Kingdom
| | - Andreas-Antonios Roussakis
- Centre for Neuroinflammation and Neurodegeneration, Division of Brain Sciences, Imperial College London, London, UK
| | - Sara De Simoni
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College, London, United Kingdom
| | - Niall Bourke
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College, London, United Kingdom
| | - Jessica Fleminger
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College, London, United Kingdom
| | - James Cole
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College, London, United Kingdom
| | - Paola Piccini
- Centre for Neuroinflammation and Neurodegeneration, Division of Brain Sciences, Imperial College London, London, UK
| | - David Sharp
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College, London, United Kingdom .,UK Dementia Research Institute, Care Research & Technology Centre, Imperial College, London, United Kingdom
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Jenkins PO, De Simoni S, Bourke NJ, Fleminger J, Scott G, Towey DJ, Svensson W, Khan S, Patel MC, Greenwood R, Friedland D, Hampshire A, Cole JH, Sharp DJ. Stratifying drug treatment of cognitive impairments after traumatic brain injury using neuroimaging. Brain 2020; 142:2367-2379. [PMID: 31199462 DOI: 10.1093/brain/awz149] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [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: 09/10/2018] [Revised: 01/26/2019] [Accepted: 04/09/2019] [Indexed: 01/12/2023] Open
Abstract
Cognitive impairment is common following traumatic brain injury. Dopaminergic drugs can enhance cognition after traumatic brain injury, but individual responses are highly variable. This may be due to variability in dopaminergic damage between patients. We investigate whether measuring dopamine transporter levels using 123I-ioflupane single-photon emission computed tomography (SPECT) predicts response to methylphenidate, a stimulant with dopaminergic effects. Forty patients with moderate-severe traumatic brain injury and cognitive impairments completed a randomized, double-blind, placebo-controlled, crossover study. 123I-ioflupane SPECT, MRI and neuropsychological testing were performed. Patients received 0.3 mg/kg of methylphenidate or placebo twice a day in 2-week blocks. Subjects received neuropsychological assessment after each block and completed daily home cognitive testing during the trial. The primary outcome measure was change in choice reaction time produced by methylphenidate and its relationship to stratification of patients into groups with normal and low dopamine transporter binding in the caudate. Overall, traumatic brain injury patients showed slow information processing speed. Patients with low caudate dopamine transporter binding showed improvement in response times with methylphenidate compared to placebo [median change = -16 ms; 95% confidence interval (CI): -28 to -3 ms; P = 0.02]. This represents a 27% improvement in the slowing produced by traumatic brain injury. Patients with normal dopamine transporter binding did not improve. Daily home-based choice reaction time results supported this: the low dopamine transporter group improved (median change -19 ms; 95% CI: -23 to -7 ms; P = 0.002) with no change in the normal dopamine transporter group (P = 0.50). The low dopamine transporter group also improved on self-reported and caregiver apathy assessments (P = 0.03 and P = 0.02, respectively). Both groups reported improvements in fatigue (P = 0.03 and P = 0.007). The cognitive effects of methylphenidate after traumatic brain injury were only seen in patients with low caudate dopamine transporter levels. This shows that identifying patients with a hypodopaminergic state after traumatic brain injury can help stratify the choice of cognitive enhancing therapy.
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Affiliation(s)
- Peter O Jenkins
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Sara De Simoni
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Niall J Bourke
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Jessica Fleminger
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Gregory Scott
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - David J Towey
- Department of Nuclear Medicine, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - William Svensson
- Department of Nuclear Medicine, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sameer Khan
- Department of Nuclear Medicine, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Maneesh C Patel
- Imaging Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Richard Greenwood
- Institute of Neurology, Division of Clinical Neurology, University College London, London, UK
| | - Daniel Friedland
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Adam Hampshire
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - James H Cole
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - David J Sharp
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK.,United Kingdom (UK) Dementia Research Institute, 6th Floor, UCL Maple House Tottenham Court Road, London, W1T 7NF, UK
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Jenkins PO, De Simoni S, Bourke NJ, Fleminger J, Scott G, Towey DJ, Svensson W, Khan S, Patel M, Greenwood R, Cole JH, Sharp DJ. Dopaminergic abnormalities following traumatic brain injury. Brain 2019; 141:797-810. [PMID: 29360949 DOI: 10.1093/brain/awx357] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 11/12/2017] [Indexed: 01/19/2023] Open
Abstract
Traumatic brain injury can reduce striatal dopamine levels. The cause of this is uncertain, but is likely to be related to damage to the nigrostriatal system. We investigated the pattern of striatal dopamine abnormalities using 123I-Ioflupane single-photon emission computed tomography (SPECT) scans and their relationship to nigrostriatal damage and clinical features. We studied 42 moderate-severe traumatic brain injury patients with cognitive impairments but no motor parkinsonism signs and 20 healthy controls. 123I-Ioflupane scanning was used to assess dopamine transporter levels. Clinical scan reports were compared to quantitative dopamine transporter results. Advanced MRI methods were used to assess the nigrostriatal system, including the area through which the nigrostriatal projections pass as defined from high-resolution Human Connectome data. Detailed clinical and neuropsychological assessments were performed. Around 20% of our moderate-severe patients had clear evidence of reduced specific binding ratios for the dopamine transporter in the striatum measured using 123I-Ioflupane SPECT. The caudate was affected more consistently than other striatal regions. Dopamine transporter abnormalities were associated with reduced substantia nigra volume. In addition, diffusion MRI provided evidence of damage to the regions through which the nigrostriatal tract passes, particularly the area traversed by dopaminergic projections to the caudate. Only a small percentage of patients had evidence of macroscopic lesions in the striatum and there was no relationship between presence of lesions and dopamine transporter specific binding ratio abnormalities. There was also no relationship between reduced volume in the striatal subregions and reduced dopamine transporter specific binding ratios. Patients with low caudate dopamine transporter specific binding ratios show impaired processing speed and executive dysfunction compared to patients with normal levels. Taken together, our results suggest that the dopaminergic system is affected by a moderate-severe traumatic brain injury in a significant proportion of patients, even in the absence of clinical motor parkinsonism. Reduced dopamine transporter levels are most commonly seen in the caudate and this is likely to reflect the pattern of nigrostriatal tract damage produced by axonal injury and associated midbrain damage.
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Affiliation(s)
- Peter O Jenkins
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Sara De Simoni
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Niall J Bourke
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Jessica Fleminger
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Gregory Scott
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - David J Towey
- Department of Nuclear Medicine, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - William Svensson
- Department of Nuclear Medicine, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sameer Khan
- Department of Nuclear Medicine, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Maneesh Patel
- Imaging Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Richard Greenwood
- Institute of Neurology, Division of Clinical Neurology, University College London, London, UK
| | - James H Cole
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - David J Sharp
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
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Fleminger S, Fleminger J. Self-harm, Traumatic Brain Injury, and Suicide. JAMA 2018; 320:2484-2485. [PMID: 30561475 DOI: 10.1001/jama.2018.17558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Goldacre B, DeVito NJ, Heneghan C, Irving F, Bacon S, Fleminger J, Curtis H. Compliance with requirement to report results on the EU Clinical Trials Register: cohort study and web resource. BMJ 2018; 362:k3218. [PMID: 30209058 PMCID: PMC6134801 DOI: 10.1136/bmj.k3218] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To ascertain compliance rates with the European Commission's requirement that all trials on the EU Clinical Trials Register (EUCTR) post results to the registry within 12 months of completion (final compliance date 21 December 2016); to identify features associated with non-compliance; to rank sponsors by compliance; and to build a tool for live ongoing audit of compliance. DESIGN Retrospective cohort study. SETTING EUCTR. PARTICIPANTS 7274 of 11 531 trials listed as completed on EUCTR and where results could be established as due. MAIN OUTCOME MEASURE Publication of results on EUCTR. RESULTS Of 7274 trials where results were due, 49.5% (95% confidence interval 48.4% to 50.7%) reported results. Trials with a commercial sponsor were substantially more likely to post results than those with a non-commercial sponsor (68.1% v 11.0%, adjusted odds ratio 23.2, 95% confidence interval 19.2 to 28.2); as were trials by a sponsor who conducted a large number of trials (77.9% v 18.4%, adjusted odds ratio 18.4, 15.3 to 22.1). More recent trials were more likely to report results (per year odds ratio 1.05, 95% confidence interval 1.03 to 1.07). Extensive evidence was found of errors, omissions, and contradictory entries in EUCTR data that prevented ascertainment of compliance for some trials. CONCLUSIONS Compliance with the European Commission requirement for all trials to post results on to the EUCTR within 12 months of completion has been poor, with half of all trials non-compliant. EU registry data commonly contain inconsistencies that might prevent even regulators assessing compliance. Accessible and timely information on the compliance status of each individual trial and sponsor may help to improve reporting rates.
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Affiliation(s)
- Ben Goldacre
- EBM DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Nicholas J DeVito
- EBM DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Carl Heneghan
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Francis Irving
- EBM DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Seb Bacon
- EBM DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Jessica Fleminger
- EBM DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Helen Curtis
- EBM DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
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Fleminger J, Goldacre B. Prevalence of clinical trial status discrepancies: A cross-sectional study of 10,492 trials registered on both ClinicalTrials.gov and the European Union Clinical Trials Register. PLoS One 2018. [PMID: 29513684 PMCID: PMC5841737 DOI: 10.1371/journal.pone.0193088] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Trial registries are a key source of information for clinicians and researchers. While building OpenTrials, an open database of public trial information, we identified errors and omissions in registries, including discrepancies between descriptions of the same trial in different registries. We set out to ascertain the prevalence of discrepancies in trial completion status using a cohort of trials registered on both the European Union Clinical Trials Register (EUCTR) and ClinicalTrials.gov. STUDY DESIGN AND SETTING We used matching titles and registry IDs provided by both registries to build a cohort of dual-registered trials. Completion statuses were compared; we calculated descriptive statistics on the prevalence of discrepancies. RESULTS 11,988 dual-registered trials were identified. 1,496 did not provide a comparable completion status, leaving 10,492 trials. 16.2% were discrepant on completion status. The majority of discrepancies (90.5%) were a 'completed' trial on ClinicalTrials.gov inaccurately marked as 'ongoing' on EUCTR. Overall, 33.9% of dual-registered trials described as 'ongoing' on EUCTR were listed as 'completed' on ClinicalTrials.gov. CONCLUSION Completion status on registries is commonly inaccurate. Previous work on publication bias may underestimate non-reporting. We describe simple steps registry owners and trialists could take to improve accuracy.
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Affiliation(s)
- Jessica Fleminger
- Centre for Evidence Based Medicine, Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ben Goldacre
- Centre for Evidence Based Medicine, Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- * E-mail:
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Jenkins PO, Simoni SD, Fleminger J, Bourke N, Jolly A, Cole J, Darian D, Sharp D. DISRUPTION TO THE DOPAMINERGIC SYSTEM AFTER TRAUMATIC BRAIN INJURY. J Neurol Neurosurg Psychiatry 2016. [DOI: 10.1136/jnnp-2016-315106.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Jenkins P, Fleminger J, De-Simoni S, Jolly A, Gorgoraptis N, Hampshire A, Sharp D. HOME COMPUTERISED COGNITIVE TESTING FOR TBI IS FEASIBLE AND POPULAR. J Neurol Neurosurg Psychiatry 2015. [DOI: 10.1136/jnnp-2015-312379.166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Serial neuropsychological testing potentially provides a powerful tool for tracking disease progress and identifying treatment response. Formal neuropsychometric assessment by a clinical psychologist is ideal but impractical for regular testing. Remote computerised assessment resolves this difficulty by allowing frequent home assessment, but is potentially limited by patient compliance and practise effects. We study the feasibility of this approach in an on-going clinical trial investigating the effects of methylphenidate on cognition after traumatic brain injury (TBI): Dopamine's Role in Enhancing Attention and Memory (DREAM).A battery of neuropsychological tests was delivered on an iPad. 12 patients with moderate/severe TBI and on-going cognitive complaints completed 7 tasks assessing information processing speed, memory, attention and executive functions. The 25-minute-long battery was performed daily for 4 weeks, following an initial training period. Compliance was good, with over 80% of the sessions completed, and patients found it both beneficial and enjoyable. Despite optimising the battery to minimise learning effects, differing tasks showed varying degrees of practise effects.We demonstrate a proof of principle that TBI patients will enthusiastically complete regular computerised neuropsychological tests at home. This provides a potentially powerful tool to assess treatment response, but also offers the prospect of facilitating self-directed cognitive rehabilitation.
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Fleminger J, Fleminger S. Ruth Fleminger (nee Jackson). West J Med 2008. [DOI: 10.1136/bmj.a1839] [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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