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Stocker MD, Smith JE, Pachepsky YA, Blaustein RA. Fine-scale spatiotemporal variations in bacterial community diversity in agricultural pond water. Sci Total Environ 2024; 915:170143. [PMID: 38242477 DOI: 10.1016/j.scitotenv.2024.170143] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 01/21/2024]
Abstract
Microbial communities in surface waters are affected by environmental conditions and can influence changes in water quality. To explore the hypothesis that the microbiome in agricultural waters associates with spatiotemporal variations in overall water quality and, in turn, has implications for resource monitoring and management, we characterized the relationships between the microbiota and physicochemical properties in a model irrigation pond as a factor of sampling time (i.e., 9:00, 12:00, 15:00) and location within the pond (i.e., bank vs. interior sites and cross-sectional depths at 0, 1, and 2 m). The microbial communities, which were defined by 16S rRNA gene sequencing analysis, significantly varied based on all sampling factors (PERMANOVA P < 0.05 for each). While the relative abundances of dominant phyla (e.g., Proteobacteria and Bacteroidetes) were relatively stable throughout the pond, subtle yet significant increases in α-diversity were observed as the day progressed (ANOVA P < 0.001). Key water quality properties that also increased between the morning and afternoon (i.e., pH, dissolved oxygen, and temperature) positively associated with relative abundances of Cyanobacteria, though were inversely proportional to Verrucomicrobia. These properties, among additional parameters such as bioavailable nutrients (e.g., NH3, NO3, PO4), chlorophyll, phycocyanin, conductivity, and colored dissolved organic matter, exhibited significant relationships with relative abundances of various bacterial genera as well. Further investigation of the microbiota in underlying sediments revealed significant differences between the bank and interior sites of the pond (P < 0.05 for α- and β-diversity). Overall, our findings emphasize the importance of accounting for time of day and water sampling location and depth when surveying the microbiomes of irrigation ponds and other small freshwater sources.
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Affiliation(s)
- M D Stocker
- United States Department of Agriculture, Agricultural Research Services, Environmental Microbial and Food Safety Laboratory, Beltsville, MD 20705, USA.
| | - J E Smith
- United States Department of Agriculture, Agricultural Research Services, Environmental Microbial and Food Safety Laboratory, Beltsville, MD 20705, USA; Oak Ridge Institute of Science and Education, Oak Ridge, TN 37830, USA
| | - Y A Pachepsky
- United States Department of Agriculture, Agricultural Research Services, Environmental Microbial and Food Safety Laboratory, Beltsville, MD 20705, USA
| | - R A Blaustein
- University of Maryland, Department of Nutrition and Food Science, College Park, MD 20742, USA
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Taylor PC, Weinblatt ME, McInnes IB, Atsumi T, Strand V, Takeuchi T, Bracher M, Brooks D, Davies J, Goode C, Gupta A, Mukherjee S, O'Shea C, Saurigny D, Schifano LA, Shelton C, Smith JE, Wang M, Wang R, Watts S, Fleischmann RM. Anti-GM-CSF otilimab versus sarilumab or placebo in patients with rheumatoid arthritis and inadequate response to targeted therapies: a phase III randomised trial (contRAst 3). Ann Rheum Dis 2023; 82:1527-1537. [PMID: 37696589 PMCID: PMC10646837 DOI: 10.1136/ard-2023-224449] [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: 05/18/2023] [Accepted: 08/23/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES To investigate the efficacy and safety of otilimab, an anti-granulocyte-macrophage colony-stimulating factor antibody, in patients with active rheumatoid arthritis and an inadequate response to conventional synthetic (cs) and biologic disease-modifying antirheumatic drugs (DMARDs) and/or Janus kinase inhibitors. METHODS ContRAst 3 was a 24-week, phase III, multicentre, randomised controlled trial. Patients received subcutaneous otilimab (90/150 mg once weekly), subcutaneous sarilumab (200 mg every 2 weeks) or placebo for 12 weeks, in addition to csDMARDs. Patients receiving placebo were switched to active interventions at week 12 and treatment continued to week 24. The primary end point was the proportion of patients achieving an American College of Rheumatology ≥20% response (ACR20) at week 12. RESULTS Overall, 549 patients received treatment. At week 12, there was no significant difference in the proportion of ACR20 responders with otilimab 90 mg and 150 mg versus placebo (45% (p=0.2868) and 51% (p=0.0596) vs 38%, respectively). There were no significant differences in Clinical Disease Activity Index, Health Assessment Questionnaire-Disability Index, pain Visual Analogue Scale or Functional Assessment of Chronic Illness Therapy-Fatigue scores with otilimab versus placebo at week 12. Sarilumab demonstrated superiority to otilimab in ACR20 response and secondary end points. The incidence of adverse or serious adverse events was similar across treatment groups. CONCLUSIONS Otilimab demonstrated an acceptable safety profile but failed to achieve the primary end point of ACR20 and improve secondary end points versus placebo or demonstrate non-inferiority to sarilumab in this patient population. TRIAL REGISTRATION NUMBER NCT04134728.
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Affiliation(s)
- Peter C Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael E Weinblatt
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Iain B McInnes
- College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto, California, USA
| | - Tsutomu Takeuchi
- Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
- Saitama Medical University, Saitama, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Roy M Fleischmann
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Metroplex Clinical Research Center, Dallas, Texas, USA
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Fleischmann RM, van der Heijde D, Strand V, Atsumi T, McInnes IB, Takeuchi T, Taylor PC, Bracher M, Brooks D, Davies J, Goode C, Gupta A, Mukherjee S, O'Shea C, Saurigny D, Schifano LA, Shelton C, Smith JE, Wang M, Wang R, Watts S, Weinblatt ME. Anti-GM-CSF otilimab versus tofacitinib or placebo in patients with active rheumatoid arthritis and an inadequate response to conventional or biologic DMARDs: two phase 3 randomised trials (contRAst 1 and contRAst 2). Ann Rheum Dis 2023; 82:1516-1526. [PMID: 37699654 PMCID: PMC10646845 DOI: 10.1136/ard-2023-224482] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/20/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVES To investigate the efficacy and safety of otilimab, an antigranulocyte-macrophage colony-stimulating factor antibody, in patients with active rheumatoid arthritis. METHODS Two phase 3, double-blind randomised controlled trials including patients with inadequate responses to methotrexate (contRAst 1) or conventional synthetic/biologic disease-modifying antirheumatic drugs (cs/bDMARDs; contRAst 2). Patients received background csDMARDs. Through a testing hierarchy, subcutaneous otilimab (90/150 mg once weekly) was compared with placebo for week 12 endpoints (after which, patients receiving placebo switched to active interventions) or oral tofacitinib (5 mg two times per day) for week 24 endpoints. PRIMARY ENDPOINT proportion of patients achieving an American College of Rheumatology response ≥20% (ACR20) at week 12. RESULTS The intention-to-treat populations comprised 1537 (contRAst 1) and 1625 (contRAst 2) patients. PRIMARY ENDPOINT proportions of ACR20 responders were statistically significantly greater with otilimab 90 mg and 150 mg vs placebo in contRAst 1 (54.7% (p=0.0023) and 50.9% (p=0.0362) vs 41.7%) and contRAst 2 (54.9% (p<0.0001) and 54.5% (p<0.0001) vs 32.5%). Secondary endpoints: in both trials, compared with placebo, otilimab increased the proportion of Clinical Disease Activity Index (CDAI) low disease activity (LDA) responders (not significant for otilimab 150 mg in contRAst 1), and reduced Health Assessment Questionnaire-Disability Index (HAQ-DI) scores. Benefits with tofacitinib were consistently greater than with otilimab across multiple endpoints. Safety outcomes were similar across treatment groups. CONCLUSIONS Although otilimab demonstrated superiority to placebo in ACR20, CDAI LDA and HAQ-DI, improved symptoms, and had an acceptable safety profile, it was inferior to tofacitinib. TRIAL REGISTRATION NUMBERS NCT03980483, NCT03970837.
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Affiliation(s)
- Roy M Fleischmann
- Department of Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Metroplex Clinical Research Center, Dallas, Texas, USA
| | | | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto, California, USA
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Iain B McInnes
- College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan
- Saitama Medical University, Saitama, Japan
| | - Peter C Taylor
- Botnar Research Centre, University of Oxford, Oxford, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michael E Weinblatt
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
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Cottey L, Smith JE, Watts S. Optimisation of mitochondrial function as a novel target for resuscitation in haemorrhagic shock: a systematic review. BMJ Mil Health 2023:e002427. [PMID: 37491136 DOI: 10.1136/military-2023-002427] [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: 04/06/2023] [Accepted: 06/10/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Traumatic injury is one of the leading causes of death worldwide, and despite significant improvements in patient care, survival in the most severely injured patients remains unchanged. There is a crucial need for innovative approaches to improve trauma patient outcomes; this is particularly pertinent in remote or austere environments with prolonged evacuation times to definitive care. Studies suggest that maintenance of cellular homeostasis is a critical component of optimal trauma patient management, and as the cell powerhouse, it is likely that mitochondria play a pivotal role. As a result, therapies that optimise mitochondrial function could be an important future target for the treatment of critically ill trauma patients. METHODS A systematic review of the literature was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol to determine the potential role of mitochondria in traumatic injury and haemorrhagic shock (HS) and to identify current evidence for mitochondrial optimisation therapies in trauma. Articles were included if they assessed a mitochondrial targeted therapy in comparison to a control group, used a model of traumatic injury and HS and reported a method to assess mitochondrial function. RESULTS The search returned 918 articles with 37 relevant studies relating to mitochondrial optimisation identified. Included studies exploring a range of therapies with potential utility in traumatic injury and HS. Therapies were categorised into the key mitochondrial pathways impacted following traumatic injury and HS: ATP levels, cell death, oxidative stress and reactive oxygen species. CONCLUSION This systematic review provides an overview of the key cellular functions of the mitochondria following traumatic injury and HS and identifies why mitochondrial optimisation could be a viable and valuable target in optimising outcome in severely injured patients in the future.
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Affiliation(s)
- Laura Cottey
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - S Watts
- Chemical, Biological and Radiological Division, Defence Science and Technology Laboratory, Salisbury, UK
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Davies RL, Thompson J, McGuire R, Smith JE, Webster S, Woolley T. Haemostatic resuscitation in practice: a descriptive analysis of blood products administered during Operation HERRICK, Afghanistan. BMJ Mil Health 2023:e002408. [PMID: 37400127 DOI: 10.1136/military-2023-002408] [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: 03/18/2023] [Accepted: 06/10/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Life-threatening haemorrhage is the leading cause of potentially survivable injury in battlefield casualties. During Operation HERRICK (Afghanistan), mortality rates improved year on year due to a number of advances in trauma care, including haemostatic resuscitation. Blood transfusion practice has not previously been reported in detail during this period. METHODS A retrospective analysis of blood transfusion at the UK role 3 medical treatment facility (MTF) at Camp Bastion between March 2006 and September 2014 was performed. Data were extracted from two sources: the UK Joint Theatre Trauma Registry (JTTR) and the newly established Deployed Blood Transfusion Database (DBTD). RESULTS 3840 casualties were transfused 72 138 units of blood and blood products. 2709 adult casualties (71%) were fully linked with JTTR data and were transfused a total of 59 842 units. Casualties received between 1 unit and 264 units of blood product with a median of 13 units per patient. Casualties wounded by explosion required almost twice the volume of blood product transfusion as those wounded by small arms fire or in a motor vehicle collision (18 units, 9 units, and 10 units, respectively). More than half of blood products were transfused within the first 2 hours following arrival at the MTF. There was a trend towards balanced resuscitation with more equal ratios of blood and blood products being used over time. CONCLUSION This study has defined the epidemiology of blood transfusion practice during Operation HERRICK. The DBTD is the largest combined trauma database of its kind. It will ensure that lessons learnt during this period are defined and not forgotten; it should also allow further research questions to be answered in this important area of resuscitation practice.
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Affiliation(s)
- Rhys L Davies
- Anaesthetic Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - J Thompson
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | | | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - S Webster
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - T Woolley
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
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Patel J, Bass D, Beishuizen A, Bocca Ruiz X, Boughanmi H, Cahn A, Colombo H, Criner GJ, Davy K, de-Miguel-Díez J, Doreski PA, Fernandes S, François B, Gupta A, Hanrott K, Hatlen T, Inman D, Isaacs JD, Jarvis E, Kostina N, Kropotina T, Lacherade JC, Lakshminarayanan D, Martinez-Ayala P, McEvoy C, Meziani F, Monchi M, Mukherjee S, Muñoz-Bermúdez R, Neisen J, O'Shea C, Plantefeve G, Schifano L, Schwab LE, Shahid Z, Shirano M, Smith JE, Sprinz E, Summers C, Terzi N, Tidswell MA, Trefilova Y, Williamson R, Wyncoll D, Layton M. A randomised trial of anti-GM-CSF otilimab in severe COVID-19 pneumonia (OSCAR). Eur Respir J 2023; 61:13993003.01870-2021. [PMID: 36229048 PMCID: PMC9558428 DOI: 10.1183/13993003.01870-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 07/02/2021] [Accepted: 08/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Granulocyte-macrophage colony-stimulating factor (GM-CSF) and dysregulated myeloid cell responses are implicated in the pathophysiology and severity of COVID-19. METHODS In this randomised, sequential, multicentre, placebo-controlled, double-blind study, adults aged 18-79 years (Part 1) or ≥70 years (Part 2) with severe COVID-19, respiratory failure and systemic inflammation (elevated C-reactive protein/ferritin) received a single intravenous infusion of otilimab 90 mg (human anti-GM-CSF monoclonal antibody) plus standard care (NCT04376684). The primary outcome was the proportion of patients alive and free of respiratory failure at Day 28. RESULTS In Part 1 (n=806 randomised 1:1 otilimab:placebo), 71% of otilimab-treated patients were alive and free of respiratory failure at Day 28 versus 67% who received placebo; the model-adjusted difference of 5.3% was not statistically significant (95% CI -0.8-11.4%, p=0.09). A nominally significant model-adjusted difference of 19.1% (95% CI 5.2-33.1%, p=0.009) was observed in the predefined 70-79 years subgroup, but this was not confirmed in Part 2 (n=350 randomised) where the model-adjusted difference was 0.9% (95% CI -9.3-11.2%, p=0.86). Compared with placebo, otilimab resulted in lower serum concentrations of key inflammatory markers, including the putative pharmacodynamic biomarker CC chemokine ligand 17, indicative of GM-CSF pathway blockade. Adverse events were comparable between groups and consistent with severe COVID-19. CONCLUSIONS There was no significant difference in the proportion of patients alive and free of respiratory failure at Day 28. However, despite the lack of clinical benefit, a reduction in inflammatory markers was observed with otilimab, in addition to an acceptable safety profile.
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Affiliation(s)
- Jatin Patel
- GSK Medicines Research Centre, Stevenage, UK
| | | | | | - Xavier Bocca Ruiz
- Servicio de Neumonologia, Clinica Monte Grande, Buenos Aires, Argentina
| | - Hatem Boughanmi
- Service de Réanimation, CH Valenciennes - Hôpital Jean Bernard, Valenciennes Cedex, France
| | | | | | - Gerard J. Criner
- Dept of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, PA, USA
| | | | - Javier de-Miguel-Díez
- Respiratory Dept, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | | | - Bruno François
- Service Réanimation Polyvalente and Inserm CIC1435 & UMR1092, CHU Limoges, Limoges Cedex, France
| | | | | | | | - Dave Inman
- GSK Medicines Research Centre, Stevenage, UK
| | - John D. Isaacs
- Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | | | - Jean-Claude Lacherade
- Service de Médecine Intensive Réanimation, CHD Vendée - Site De La Roche-sur-Yon, La Roche-Sur-Yon, France
| | | | | | - Charlene McEvoy
- Regions Hospital, St. Paul, MN, USA
- Methodist Hospital, St. Louis Park, MN, USA
- HealthPartners Institute, Bloomington, MN, USA
| | - Ferhat Meziani
- Dept of Intensive Care, Service de Médecine Intensive - Réanimation, Nouvel Hôpital Civil, Hôpital Universitaire de Strasbourg, Strasbourg, France
- CRICS-TRIGGERSEP F-CRIN Network, Strasbourg, France
| | | | | | | | | | | | - Gaëtan Plantefeve
- Service de Réanimation Polyvalente, CH Victor Dupouy, Argenteuil, France
| | | | | | - Zainab Shahid
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | | | - Eduardo Sprinz
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Charlotte Summers
- Dept of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Nicolas Terzi
- Médecine Intensive Réanimation, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble-Alpes, Grenoble, France
- INSERM U1042, Grenoble, France
| | - Mark A. Tidswell
- Pulmonary and Critical Care, Baystate Medical Centre, Springfield, MA, USA
| | | | | | - Duncan Wyncoll
- Dept of Critical Care, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Mark Layton
- GSK Medicines Research Centre, Stevenage, UK
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Wood F, Roiz-de-Sa D, Pynn H, Smith JE, Bishop J, Hemingway R. Outcomes of UK military personnel treated with ice cold water immersion for exertional heat stroke. BMJ Mil Health 2022:e002133. [PMID: 36202428 DOI: 10.1136/military-2022-002133] [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: 04/11/2022] [Accepted: 09/09/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Despite mitigation efforts, exertional heat stroke (EHS) is known to occur in military personnel during training and operations. It has significant potential to cause preventable morbidity and mortality. International consensus from sports medicine organisations supports treating EHS with early rapid cooling by immersing the casualty in cold water. However, evidence remains sparse and the practice is not yet widespread in the UK. METHODS Following changes to enable on-site ice cold water immersion (ICWI) at the Royal Marines Commando Training Centre, Lympstone, UK, we prospectively gathered data on 35 patients treated with ICWI over a 3-year period. These data included the incidence of adverse events (e.g. death, cardiac arrest or critical care admission) as the primary outcome. Basic anthropometric data, cooling rates achieved and biochemical and haematological test results on days 0-5 were also gathered and analysed. RESULTS Despite being a cohort of patients in whom we might expect significant morbidity and mortality based on the severity of EHS at presentation, none experienced a serious adverse event. In this cohort with rapid initiation of effective cooling, biochemical derangement appeared less severe than that reported in previous studies. Higher body mass index (BMI) was associated with a lower cooling rate across a range of values previously reported as potentially of clinical significance. CONCLUSIONS This case series supports recent updates to UK military guidance that ICWI should be more widely adopted for the treatment of EHS. Clinicians should be aware of likely patterns of blood test abnormalities in the days following EHS. Further work should seek to establish the impact of lower rates of cooling and develop strategies to optimise cooling in patients with higher BMI.
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Affiliation(s)
- Felix Wood
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | | | - H Pynn
- Emergency Department, Bristol Royal Infirmary, Bristol, UK
- Royal Army Medical Corps, Aldershot, UK
| | - J E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - J Bishop
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - R Hemingway
- Medical Centre, Commando Training Centre Royal Marines, Lympstone, UK
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Genovese MC, Buckley CD, Saurigny D, Schett G, Davy K, Gupta A, Smith JE, Patel J, Tak PP. Targeting GM-CSF in rheumatological conditions: risk of PAP - Authors' reply. Lancet Rheumatol 2021; 3:e473-e474. [PMID: 38279397 DOI: 10.1016/s2665-9913(21)00146-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/16/2021] [Indexed: 01/28/2024]
Affiliation(s)
- Mark C Genovese
- Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, USA
| | - Christopher D Buckley
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK; Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | | | - Georg Schett
- Department of Internal Medicine 3, University of Erlangen-Nurnberg and Universitatsklinikum Erlangen, Erlangen, Germany
| | | | - Anubha Gupta
- Clinical Pharmacology Modeling and Simulation, GlaxoSmithKline, Stevenage SG1 2NY, UK
| | - Julia E Smith
- ImmunoInflammation, GlaxoSmithKline, Stevenage SG1 2NY, UK
| | - Jatin Patel
- ImmunoInflammation, GlaxoSmithKline, Middlesex, UK
| | - Paul P Tak
- Research and Development, GlaxoSmithKline, Stevenage SG1 2NY, UK.
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Nordmann G, Ralph J, Smith JE. Evolution of the deployed medical director role in an era of contingency operations: reflections from a United Nations operation. BMJ Mil Health 2021; 167:335-339. [PMID: 34083373 DOI: 10.1136/bmjmilitary-2020-001690] [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: 01/09/2021] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/04/2022]
Abstract
This paper examines the development and evolution of the deployed medical director (DMD) role and argues for the re-establishment of a formal selection process and training pathway. Recent deployments into new areas of operations, deployment of smaller medical treatment facilities (MTFs), the reduced numbers of deployments for clinicians, working with various multinational partners and both military and civilian organisations all pose specific problems for DMDs. The initial and then continued deployment of a secondary care role 2 MTF as part of the United Nations Mission in South Sudan illustrated some of these challenges. Although a novel operation, the broad categories of these new challenges were similar to the historical challenges facing the first DMDs in Afghanistan. Corporate memory loss may be unavoidable to some degree due to rapid turnover in appointments, particularly in single service and joint headquarters. However, individual memory and experience remains extant within the military medical deployable workforce. After the cessation of UK military deployed hospital care involvement in Afghanistan, the UK DMD formal training pathway ended. This paper argues for the re-establishment of a more formal DMD selection process and training pathway to ensure that organisational learning is optimised.
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Affiliation(s)
- Giles Nordmann
- Academic Department of Anaesthesia, Royal Centre for Defence Medicine, Birmingham, UK .,Head of Capability Combat Service Support (Medical), Capability Directorate, UK Army Headquarters, Andover, UK
| | - J Ralph
- Royal Centre for Defence Medicine Clinical Unit, Queen Elizabeth Hospital, Birmingham, West Midlands, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.,Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
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Genovese MC, Berkowitz M, Conaghan PG, Peterfy C, Davy K, Fisheleva E, Gupta A, Inman D, Janiczek R, Layton M, Mitchell N, Patel J, Roberts A, Saurigny D, Smith JE, Williamson R, Tak PP. MRI of the joint and evaluation of the granulocyte-macrophage colony-stimulating factor-CCL17 axis in patients with rheumatoid arthritis receiving otilimab: a phase 2a randomised mechanistic study. Lancet Rheumatol 2020; 2:e666-e676. [PMID: 38279363 DOI: 10.1016/s2665-9913(20)30224-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/29/2020] [Accepted: 06/23/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Otilimab is a human monoclonal antibody that inhibits granulocyte-macrophage colony-stimulating factor (GM-CSF), a driver in many immune-mediated inflammatory conditions. We evaluated the effect of otilimab on the GM-CSF-chemokine (C-C motif) ligand 17 (CCL17) axis and synovitis in patients with rheumatoid arthritis. METHODS This phase 2a, randomised, double-blind, multicentre, placebo-controlled, parallel-group study was done at nine sites across the USA, Poland, and Germany. Patients aged 18 years or older with rheumatoid arthritis per American College of Rheumatology-European League Against Rheumatism 2010 criteria and receiving stable methotrexate were randomly assigned (3:1) by an interactive response technology system to either subcutaneous otilimab 180 mg or placebo once weekly for 5 weeks, then every other week until week 10 (within a 12-week treatment period), followed by a 10-week safety follow-up. Randomisation was stratified by early rheumatoid arthritis (≤2 years since diagnosis) and established rheumatoid arthritis (>2 years since diagnosis). Patients and study personnel (except for an unblinded coordinator or nurse who prepared and administered the study drug) were blinded to treatment assignment; the syringe was shielded during administration. Patients were enrolled by study investigators and allocated to a treatment by central randomisation on the basis of a schedule generated by the sponsor. The primary endpoint was change over time (assessed at baseline and weeks 1, 2, 4, 6, 8, 12, and 22 of follow-up) in 112 biomarkers, including target engagement biomarkers and those that may be indicative of rheumatoid arthritis disease activity and response to otilimab. Secondary endpoints were change from baseline in synovitis, osteitis and erosion assessed by rheumatoid arthritis MRI scoring system (RAMRIS) and rheumatoid arthritis MRI quantitative score (RAMRIQ), and safety evaluation. The primary, secondary, and safety endpoints were assessed in the intention-to-treat population. Biomarker and MRI endpoints were analysed for differences between treatment groups using a repeated measures model. This study is registered with ClinicalTrials.gov, NCT02799472. FINDINGS Between Aug 9, 2016, and Oct 30, 2017, 39 patients were randomly assigned and included in the analysis (otilimab n=28; placebo n=11). In the otilimab group, mean serum concentrations of GM-CSF-otilimab complex peaked at week 4 (138·4 ng/L, 95% CI 90·0-212·9) but decreased from week 6-12. CCL17 concentrations decreased from baseline to week 1, remained stable to week 8, and returned to baseline at week 12; least-squares mean ratio to baseline was 0·65 (95% CI 0·49-0·86; coefficient of variation 13·60) at week 2, 0·68 (0·53-0·88; 12·51) at week 4, 0·78 (0·60-1·00; 12·48) at week 6, and 0·68 (0·54-0·85; 11·21) at week 8. No meaningful change in CCL17 concentrations was observed with placebo. In the otilimab group, the least-squares mean ratio to baseline in MMP-degraded type I collagen was 0·86-0·91 over weeks 1-8, returning to baseline at week 12; concentrations remained above baseline at all timepoints in the placebo group. There were no observable differences between otilimab and placebo for all other biomarkers. At week 12, least-squares mean change in RAMRIS synovitis score from baseline was -1·3 (standard error [SE] 0·6) in the otilimab group and 0·8 (1·2) with placebo; RAMRIQ synovitis score showed a least-squares mean change from baseline of -1417·0 μl (671·5) in the otilimab group and -912·3 μl (1405·8) with placebo. Compared with placebo, otilimab did not show significant reductions from baseline to week 12 in RAMRIS synovitis, osteitis and bone erosion, or in RAMRIQ synovitis and erosion damage. Adverse events were reported in 11 (39%) of 28 otilimab-treated and four (36%) of 11 placebo-treated patients, most commonly cough in the otilimab group (2 [7%] of 28; not reported in placebo group), and pain in extremity (four [36%] of 11) and rheumatoid arthritis (two [18%] of 11) in the placebo group (not reported in otilimab group). There were no serious adverse events or deaths. INTERPRETATION Serum concentrations of GM-CSF-otilimab complex indicated that target engagement was achieved with initial weekly dosing, but not sustained with every other week dosing. CCL17 might be a pharmacodynamic biomarker for otilimab activity in future studies. Otilimab was well tolerated and, despite suboptimal exposure, showed some evidence for improved synovitis over 12 weeks in patients with active rheumatoid arthritis. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Mark C Genovese
- Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, USA.
| | | | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds, UK
| | | | - Katherine Davy
- Statistics, GlaxoSmithKline, Stevenage, Hertfordshire, UK
| | - Elena Fisheleva
- ImmunoInflammation, GlaxoSmithKline, Stevenage, Hertfordshire, UK
| | - Anubha Gupta
- Clinical Pharmacology Modeling and Simulation, GlaxoSmithKline, Stevenage, Hertfordshire, UK
| | - David Inman
- Statistics, GlaxoSmithKline, Stevenage, Hertfordshire, UK
| | - Robert Janiczek
- Experimental Medicine Imaging, GlaxoSmithKline, Stevenage, Hertfordshire, UK
| | - Mark Layton
- ImmunoInflammation, GlaxoSmithKline, Stevenage, Hertfordshire, UK
| | - Nina Mitchell
- ImmunoInflammation, GlaxoSmithKline, Stevenage, Hertfordshire, UK
| | - Jatin Patel
- ImmunoInflammation, GlaxoSmithKline, Stockley Park, Uxbridge, Middlesex, UK
| | - Alexandra Roberts
- Experimental Medicine Imaging, GlaxoSmithKline, Stevenage, Hertfordshire, UK
| | - Didier Saurigny
- ImmunoInflammation, GlaxoSmithKline, Stevenage, Hertfordshire, UK
| | - Julia E Smith
- ImmunoInflammation, GlaxoSmithKline, Stevenage, Hertfordshire, UK
| | - Russell Williamson
- ImmunoInflammation, GlaxoSmithKline, Stockley Park, Uxbridge, Middlesex, UK
| | - Paul P Tak
- Research and Development, GlaxoSmithKline, Stevenage, Hertfordshire, UK
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11
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Smith JE, Stocker MD, Wolny JL, Hill RL, Pachepsky YA. Intraseasonal variation of phycocyanin concentrations and environmental covariates in two agricultural irrigation ponds in Maryland, USA. Environ Monit Assess 2020; 192:706. [PMID: 33064217 DOI: 10.1007/s10661-020-08664-w] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 10/05/2020] [Indexed: 06/11/2023]
Abstract
Recently, cyanobacteria blooms have become a concern for agricultural irrigation water quality. Numerous studies have shown that cyanotoxins from these harmful algal blooms (HABs) can be transported to and assimilated into crops when present in irrigation waters. Phycocyanin is a pigment known only to occur in cyanobacteria and is often used to indicate cyanobacteria presence in waters. The objective of this work was to identify the most influential environmental covariates affecting the phycocyanin concentrations in agricultural irrigation ponds that experience cyanobacteria blooms of the potentially toxigenic species Microcystis and Aphanizomenon using machine learning methodology. The study was performed at two agricultural irrigation ponds over a 5-month period in the summer of 2018. Phycocyanin concentrations, along with sensor-based and fluorometer-based water quality parameters including turbidity (NTU), pH, dissolved oxygen (DO), fluorescent dissolved organic matter (fDOM), conductivity, chlorophyll, color dissolved organic matter (CDOM), and extracted chlorophyll were measured. Regression tree analyses were used to determine the most influential water quality parameters on phycocyanin concentrations. Nearshore sampling locations had higher phycocyanin concentrations than interior sampling locations and "zones" of consistently higher concentrations of phycocyanin were found in both ponds. The regression tree analyses indicated extracted chlorophyll, CDOM, and NTU were the three most influential parameters on phycocyanin concentrations. This study indicates that sensor-based and fluorometer-based water quality parameters could be useful to identify spatial patterns of phycocyanin concentrations and therefore, cyanobacteria blooms, in agricultural irrigation ponds and potentially other water bodies.
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Affiliation(s)
- J E Smith
- Environmental Microbial and Food Safety Laboratory, Beltsville Agricultural Research Center, ARS-USDA, Beltsville, MD, USA.
- Department of Environmental Science and Technology, University of Maryland, College Park, MD, USA.
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA.
| | - M D Stocker
- Environmental Microbial and Food Safety Laboratory, Beltsville Agricultural Research Center, ARS-USDA, Beltsville, MD, USA
- Department of Environmental Science and Technology, University of Maryland, College Park, MD, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - J L Wolny
- Resource Assessment Service, Maryland Department of Natural Resources, Annapolis, MD, USA
| | - R L Hill
- Department of Environmental Science and Technology, University of Maryland, College Park, MD, USA
| | - Y A Pachepsky
- Environmental Microbial and Food Safety Laboratory, Beltsville Agricultural Research Center, ARS-USDA, Beltsville, MD, USA
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12
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Schett G, Bainbridge C, Berkowitz M, Davy K, Fernandes S, Griep E, Harrison S, Gupta A, Lloyd-Hughes J, Roberts A, Layton M, Nowak NA, Patel J, Rech J, Smith JE, Watts S, Tak PP. Anti-granulocyte-macrophage colony-stimulating factor antibody otilimab in patients with hand osteoarthritis: a phase 2a randomised trial. Lancet Rheumatol 2020; 2:e623-e632. [PMID: 38273625 DOI: 10.1016/s2665-9913(20)30171-5] [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] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/05/2020] [Accepted: 05/19/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a key mediator of signs and symptoms in preclinical models of osteoarthritis. We explored the efficacy, safety, and pharmacokinetics of an anti-GM-CSF antibody, otilimab, in patients with hand osteoarthritis. METHODS This double-blind, randomised, placebo-controlled phase 2a study was done in 16 centres in the Netherlands, Germany, Poland, the UK, and the USA. Patients aged 18 years or older with inflammatory hand osteoarthritis, who had received at least one course of unsuccessful non-steroidal anti-inflammatory drugs, with two or more swollen and tender interphalangeal joints (on the same hand), signs of inflammation or synovitis identified with MRI in the affected hand, and a self-reported 24 h average hand pain intensity over the past 7 days of 5 or more on a 0-10 numerical rating scale were eligible for inclusion. Patients were randomly assigned (1:1) via interactive response technology (blocked randomisation; block size of four) to receive either subcutaneous otilimab 180 mg or placebo, administered weekly from week 0 to week 4, then every other week until week 10. Patients, investigators, and trial staff were masked to treatment; at least one administrator at each site was unmasked to prepare and administer treatment. The primary endpoint was change from baseline in 24 h average hand pain numeric rating scale averaged over 7 days before the visit at week 6. Secondary endpoints were: change from baseline in 24 h average and worst hand pain intensity at each visit; proportion of patients showing 30% and 50% reductions in 24 h average and worst hand pain intensity at each visit; change from baseline in Australian and Canadian Hand Osteoarthritis Index (AUSCAN) 3·1 numeric rating scale questionnaire components at each visit; change in number of swollen and tender hand joints at each visit; change from baseline in Patient and Physician Global Assessment of disease activity; serum concentration of otilimab; and safety parameters. Efficacy endpoints were assessed in the intention-to-treat population. The safety population included all patients who received at least one dose of study treatment. The study is registered with ClinicalTrials.gov, NCT02683785. FINDINGS Between March 17, 2016, and Nov 29, 2017, 44 patients were randomly assigned (22 in the placebo group and 22 in the otilimab group). At week 6, difference in change from baseline in 24 h average hand pain numeric rating scale between the otilimab and placebo groups was -0·36 (95% CI -1·31 to 0·58; p=0·44); at week 12, the difference was -0·89 (-2·06 to 0·28; p=0·13). Patients receiving otilimab showed greater improvement in AUSCAN components versus placebo at each visit. The change from baseline in the 24 h worst hand pain numeric rating scale in the otilimab group at week 6 showed a difference over placebo of -0·33 (95% CI -1·28 to 0·63; p=0·49); at week 12, this difference was -1·01 (95% CI -2·22 to 0·20; p=0·098). The proportion of patients achieving 30% or higher or 50% or higher reduction from baseline in the 24 h average and worst hand pain numeric rating scale scores was consistently greater (although non-significant) with otilimab versus placebo. Similarly, patients receiving otilimab showed greater improvement in AUSCAN pain, functional impairment, and stiffness scores versus placebo at each visit. No differences were observed between otilimab and placebo in the change from baseline in the number of swollen and tender joints across the study. The Patient Global Assessment was consistently lower than placebo at all visits; the Physician Global Assessment showed reductions across the study period, but the changes were similar in both treatment groups. Median otilimab serum concentrations increased during weekly dosing from 1730 ng/mL at week 1 to a maximum of 3670 ng/mL at week 4, but declined after transitioning to dosing every other week (weeks 6-10). In total, 84 adverse events were reported by 24 patients: 54 adverse events in 13 (59%) patients in the otilimab group and 30 adverse events in 11 (50%) patients in the placebo group. The most common adverse events were cough (reported in 4 [9%] patients; 2 in each group), and nasopharyngitis (in 3 [7%] patients; 1 in the placebo group and 2 in the otilimab group). Three serious adverse events occurred in this study (all in the otilimab group) and were deemed not related to the study medication. There were no deaths during the study. INTERPRETATION There was no significant difference between otilimab and placebo in the primary endpoint, although we noted a non-significant trend towards a reduction in pain and functional impairment with otilimab, which supports a potential role for GM-CSF in hand osteoarthritis-associated pain. There were no unexpected safety findings in this study, with no treatment-related serious adverse events reported. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Georg Schett
- Department of Internal Medicine 3, University of Erlangen-Nurnberg and Universitatsklinikum Erlangen, Erlangen, Germany
| | | | - Mario Berkowitz
- Orthopedic Surgery, Leon Medical Research, Lauderdale Lakes, FL, USA
| | | | | | | | | | - Anubha Gupta
- Clinical Pharmacology, Stevenage, Hertfordshire, UK
| | | | | | - Mark Layton
- ImmunoInflammation, Stevenage, Hertfordshire, UK
| | | | - Jatin Patel
- ImmunoInflammation, GlaxoSmithKline, Stockley Park, Uxbridge, UK
| | - Jürgen Rech
- Department of Internal Medicine 3, University of Erlangen-Nurnberg and Universitatsklinikum Erlangen, Erlangen, Germany
| | | | | | - Paul P Tak
- Research & Development, GlaxoSmithKline, Stevenage, Hertfordshire, UK.
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13
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Shi H, Chen L, Ridley A, Zaarour N, Brough I, Caucci C, Smith JE, Bowness P. GM-CSF Primes Proinflammatory Monocyte Responses in Ankylosing Spondylitis. Front Immunol 2020; 11:1520. [PMID: 32765525 PMCID: PMC7378736 DOI: 10.3389/fimmu.2020.01520] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Received: 03/05/2020] [Accepted: 06/09/2020] [Indexed: 01/31/2023] Open
Abstract
Objectives: GM-CSF is a pro-inflammatory cytokine with multiple actions predominantly on myeloid cells. Enhanced GM-CSF expression by lymphocytes from patients with Ankylosing Spondylitis (AS) has recently been described, however, its potential pathogenic role(s) in AS are unknown. Methods: The effects of GM-CSF on TNF, IL-23, and CCL17 production by blood, PBMCs and isolated CD14+ monocytes from AS patients and healthy controls (HCs) were studied using ELISA. Serum CCL17 and GM-CSF and T cell GM-CSF production were studied in AS patients including pre-and on TNFi therapy. Results: GM-CSF markedly increased TNF production by LPS-stimulated whole blood, peripheral blood mononuclear cells (PBMC) and purified monocytes from AS patients, with 2 h GM-CSF exposure sufficient for monocyte "priming." Blocking of GM-CSF significantly reduced the production of TNF by whole blood from AS patients but not HCs. GM-CSF priming increased IL-23 production from LPS-stimulated AS and HC whole blood 5-fold, with baseline and stimulated IL-23 levels being significantly higher in AS whole blood. GM-CSF also stimulated CCL17 production from AS and HC blood and CCL17 levels were elevated in AS plasma. GM-CSF could be detected in plasma from 14/46 (30%) AS patients compared to 3/18 (17%) HC. Conclusion: We provide evidence that GM-CSF primes TNF and IL-23 responses in myeloid cells from AS patients and HC. We also show CCL17 levels, downstream of GM-CSF, were elevated in plasma samples of AS patients. Taken together these observations are supportive of GM-CSF neutralization as a potential novel therapeutic approach for the treatment of AS.
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Affiliation(s)
- Hui Shi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Liye Chen
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Anna Ridley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Nancy Zaarour
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - India Brough
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Cherilyn Caucci
- Bioanalysis, Immunogenicity & Biomarkers, GlaxoSmithKline, Collegeville, PA, United States
| | - Julia E Smith
- Adaptive Immunity, GlaxoSmithKline, Stevenage, United Kingdom
| | - Paul Bowness
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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14
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Webster S, Barnard EBG, Smith JE, Marsden MER, Wright C. Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014). BMJ Mil Health 2020; 167:84-88. [PMID: 32487673 DOI: 10.1136/bmjmilitary-2020-001490] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 04/14/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care. METHODS The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004-2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR). RESULTS 2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5-75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0-21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant. CONCLUSION Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.
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Affiliation(s)
- Stacey Webster
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK .,The 2nd Battalion Parachute Regiment, Colchester, UK
| | - E B G Barnard
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK.,Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
| | - M E R Marsden
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK.,Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - C Wright
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
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15
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Lee KMC, Zhang Z, Achuthan A, Fleetwood AJ, Smith JE, Hamilton JA, Cook AD. IL-23 in arthritic and inflammatory pain development in mice. Arthritis Res Ther 2020; 22:123. [PMID: 32471485 PMCID: PMC7345543 DOI: 10.1186/s13075-020-02212-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/06/2020] [Indexed: 12/12/2022] Open
Abstract
Background The cytokine, interleukin-23 (IL-23), can be critical for the progression of inflammatory diseases, including arthritis, and is often associated with T lymphocyte biology. We previously showed that certain lymphocyte-independent, inflammatory arthritis and pain models have a similar requirement for tumour necrosis factor (TNF), granulocyte macrophage-colony stimulating factor (GM-CSF), and C-C motif ligand 17 (CCL17). Given this correlation in cytokine requirements, we explored whether IL-23 might interact with this cytokine cluster in the control of arthritic and inflammatory pain. Methods The role of IL-23 in the development of pain-like behaviour was investigated using mouse arthritis models (zymosan-induced arthritis and GM-CSF-, TNF-, and CCL17-driven monoarticular arthritis) and inflammatory pain models (intraplantar zymosan, GM-CSF, TNF, and CCL17). Additionally, IL-23-induced inflammatory pain was measured in GM-CSF−/−, Tnf−/−, and Ccl17E/E mice and in the presence of indomethacin. Pain-like behaviour and arthritis were assessed by relative weight distribution in hindlimbs and histology, respectively. Cytokine mRNA expression in knees and paw skin was analysed by quantitative PCR. Blood and synovial cell populations were analysed by flow cytometry. Results We report, using Il23p19−/− mice, that innate immune (zymosan)-driven arthritic pain-like behaviour (herein referred to as pain) was completely dependent upon IL-23; optimal arthritic disease development required IL-23 (P < 0.05). Zymosan-induced inflammatory pain was also completely dependent on IL-23. In addition, we found that exogenous TNF-, GM-CSF-, and CCL17-driven arthritic pain, as well as inflammatory pain driven by each of these cytokines, were absent in Il23p19−/− mice; optimal disease in these mBSA-primed models was dependent on IL-23 (P < 0.05). Supporting this cytokine connection, it was found conversely that IL-23 (200 ng) can induce inflammatory pain at 4 h (P < 0.0001) with a requirement for each of the other cytokines as well as cyclooxygenase activity. Conclusions These findings indicate a role for IL-23 in innate immune-mediated arthritic and inflammatory pain with potential links to TNF, GM-CSF, CCL17, and eicosanoid function.
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Affiliation(s)
- Kevin M-C Lee
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, 3050, Australia.
| | - Zihao Zhang
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, 3050, Australia
| | - Adrian Achuthan
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, 3050, Australia
| | - Andrew J Fleetwood
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, 3050, Australia
| | - Julia E Smith
- Adaptive Immunity, GSK Medicines Research Centre, Stevenage, Hertfordshire, UK
| | - John A Hamilton
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, 3050, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St. Albans, Victoria, Australia
| | - Andrew D Cook
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, 3050, Australia
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16
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Lee KMC, Jarnicki A, Achuthan A, Fleetwood AJ, Anderson GP, Ellson C, Feeney M, Modis LK, Smith JE, Hamilton JA, Cook A. CCL17 in Inflammation and Pain. J Immunol 2020; 205:213-222. [PMID: 32461237 DOI: 10.4049/jimmunol.2000315] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/28/2020] [Indexed: 12/12/2022]
Abstract
It has been reported that a GM-CSF→CCL17 pathway, originally identified in vitro in macrophage lineage populations, is implicated in the control of inflammatory pain, as well as arthritic pain and disease. We explore, in this study and in various inflammation models, the cellular CCL17 expression and its GM-CSF dependence as well as the function of CCL17 in inflammation and pain. This study used models allowing the convenient cell isolation from Ccl17E/+ reporter mice; it also exploited both CCL17-dependent and unique CCL17-driven inflammatory pain and arthritis models, the latter permitting a radiation chimera approach to help identify the CCL17 responding cell type(s) and the mediators downstream of CCL17 in the control of inflammation and pain. We present evidence that 1) in the particular inflammation models studied, CCL17 expression is predominantly in macrophage lineage populations and is GM-CSF dependent, 2) for its action in arthritic pain and disease development, CCL17 acts on CCR4+ non-bone marrow-derived cells, and 3) for inflammatory pain development in which a GM-CSF→CCL17 pathway appears critical, nerve growth factor, CGRP, and substance P all appear to be required.
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Affiliation(s)
- Kevin M-C Lee
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia;
| | - Andrew Jarnicki
- Department of Pharmacology, The University of Melbourne, Parkville, Victoria 3050, Australia
| | - Adrian Achuthan
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia
| | - Andrew J Fleetwood
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia
| | - Gary P Anderson
- Department of Pharmacology, The University of Melbourne, Parkville, Victoria 3050, Australia
| | - Christian Ellson
- Adaptive Immunity Research Unit, GlaxoSmithKline, Stevenage, Hertfordshire SG1 2NY, United Kingdom; and
| | - Maria Feeney
- Adaptive Immunity Research Unit, GlaxoSmithKline, Stevenage, Hertfordshire SG1 2NY, United Kingdom; and
| | - Louise K Modis
- Adaptive Immunity Research Unit, GlaxoSmithKline, Stevenage, Hertfordshire SG1 2NY, United Kingdom; and
| | - Julia E Smith
- Adaptive Immunity Research Unit, GlaxoSmithKline, Stevenage, Hertfordshire SG1 2NY, United Kingdom; and
| | - John A Hamilton
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia.,Australian Institute for Musculoskeletal Science, The University of Melbourne and Western Health, St. Albans, Victoria 3021, Australia
| | - Andrew Cook
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia
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17
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Horne S, Gurney I, Smith JE. UK Defence Medical Services’ support to the development of a multiagency major incident plan in South Sudan. BMJ Mil Health 2020; 167:330-334. [DOI: 10.1136/jramc-2019-001264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 11/03/2022]
Abstract
UK Defence Medical Services personnel deployed in support of the United Nations Mission in South Sudan as part of Operation TRENTON in 2017–2018. One key contribution was the development of a multiagency major incident plan in collaboration with key stakeholders within the region, including our UN partners, other troop-contributing countries and non-governmental organisations. This paper describes the process and contribution made, with some transferable lessons for future similar operations, such as adaptation of our courses. Major incident management is one of several technical areas ripe for a proactive Defence Healthcare Engagement strategy, seeking to offer capacity building in areas where Defence is rich in expertise that is highly sought after by other sectors.
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Jeyanathan J, Smith JE, Sellon E. Civil-military cooperation on operational deployment: the Bentiu State Hospital medical training programme. BMJ Mil Health 2020; 167:353-355. [PMID: 32123004 PMCID: PMC8485134 DOI: 10.1136/jramc-2019-001302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 08/06/2019] [Indexed: 11/25/2022]
Abstract
The United Nations Mission in South Sudan has a mandate to protect civilians and support the delivery of humanitarian assistance. Recognising this during Operation TRENTON, UK staff of the UN level 2 hospital were able to support the people of Bentiu through initiatives to develop local health services with on-the-ground civil–military cooperation. The Bentiu State Hospital Medical Training Programme was developed to train and mentor staff associated with healthcare in Bentiu, to help improve service delivery, support local health services with on-the-ground non-governmental organisation/military coordination and to create a platform to facilitate the sharing of information to support local health services with the overall humanitarian response. It was recognised how important it was to deliver a programme that carefully understood the unique challenging limitations, circumstances and environment. Hence careful tailoring of the programme was essential to ensure that the training was valuable, implementable and durable, long beyond the operational deployment of TRENTON. Despite the logistical and practical complexities, the programme was very positively received, and the training team believed that the development and progress made would build a small part of the future infrastructure of healthcare delivery in the region. Future contingency operations are likely to take place in the resource- limited austere environment. As reflected in this deployed initiative, local health training activity providing key knowledge to build resilience for the current and immediate future is a precious and important defence engagement utility.
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Affiliation(s)
- Jeyasankar Jeyanathan
- Academic Department of Military Anaesthesia and Critical Care, Institute of Research and Development, Birmingham Research Park, Birmingham, UK .,Department of Intensive Care Medicine and Department of Anaesthetics, St George's University Hospital London, London, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.,Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - E Sellon
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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19
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Jeyanathan J, O'Brien D, Smith JE. Intensive care medicine on military operations in the resource-limited environment: a case series. BMJ Mil Health 2020; 167:320-322. [PMID: 32123005 DOI: 10.1136/jramc-2019-001344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 10/13/2019] [Accepted: 10/16/2019] [Indexed: 11/04/2022]
Abstract
This paper describes a series of critically ill patients who were cared for at a UK military field hospital during Op TRENTON 4, in support of the United Nations Mission in South Sudan. These cases highlight the potential challenges in managing the critically ill patient during contingency operations that take place in an austere resource-limited environment.
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Affiliation(s)
- Jeyasankar Jeyanathan
- Academic Department of Military Anaesthesia and Critical Care, Institute of Research and Development, Birmingham Research Park, Birmingham, UK .,Department of Intensive Care Medicine and Department of Anaesthetics, St George's University Hospital London, London, UK
| | - D O'Brien
- Department of Intensive Care Medicine, Buckinghamshire Healthcare NHS Trust, Aylesbury, Buckinghamshire, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.,Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Cottey L, Jefferys S, Woolley T, Smith JE. Use of supplemental oxygen in emergency patients: a systematic review and recommendations for military clinical practice. J ROY ARMY MED CORPS 2018; 165:416-420. [PMID: 30554164 DOI: 10.1136/jramc-2018-001076] [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: 09/21/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Supplemental oxygen is a key element of emergency treatment algorithms. However, in the operational environment, oxygen supply poses a challenge. The lack of high-quality evidence alongside emerging technologies provides the opportunity to challenge current guidelines. The aim of this review was to appraise the evidence for the administration of oxygen in emergency patients and give recommendations for its use in clinical practice. METHODS A critical review of the literature was undertaken to determine the evidence for emergency supplemental oxygen use. RESULTS Based on interpretation of the limited available evidence, five key recommendations are made: pulse oximetry should be continuous and initiated as early as possible; oxygen should be available to all trauma and medical patients in the forward operating environment; if peripheral oxygen saturations (SpO2) are greater than or equal to 92%, supplemental oxygen is not routinely required; if SpO2 is less than 92%, supplemental oxygen should be titrated to achieve an SpO2 of greater than 92%; and if flow rates of greater than 5 L/min are required, then urgent evacuation and critical care support should be requested. CONCLUSION Oxygen is not universally required for all patients. Current guidelines aim to prevent hypoxia but with potentially conservative limits. Oxygen should be administered to maintain SpO2 at 92% or above. New areas for research, highlighted in this review, may provide a future approach for oxygen use from point of injury to definitive care.
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Affiliation(s)
- Laura Cottey
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK .,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - S Jefferys
- Emergency Department, Chelsea and Westminster NHS Foundation Trust, London, UK.,Army Medical Service, Support Unit, Camberley, UK
| | - T Woolley
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK.,Anaesthetic Department, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - J E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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21
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Vassallo J, Smith JE. Authors response: Marsden MER, Mossadegh S, Marsh W, et al. J R Army Med Corps Epub ahead of print. doi:10.1136/jramc-2018-001057. BMJ Mil Health 2018; 166:205. [PMID: 30455391 DOI: 10.1136/jramc-2018-001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 10/01/2018] [Indexed: 11/04/2022]
Affiliation(s)
- James Vassallo
- Institute of Naval Medicine, Hampshire, UK .,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, United Kingdom.,Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
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22
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Rockett M, Creanor S, Squire R, Barton A, Benger J, Cocking L, Ewings P, Eyre V, Smith JE. The impact of emergency department patient-controlled analgesia (PCA) on the incidence of chronic pain following trauma and non-traumatic abdominal pain. Anaesthesia 2018; 74:69-73. [PMID: 30367688 PMCID: PMC6587467 DOI: 10.1111/anae.14476] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2018] [Indexed: 12/19/2022]
Abstract
The effect of patient-controlled analgesia during the emergency phase of care on the prevalence of persistent pain is unkown. We studied individuals with traumatic injuries or abdominal pain 6 months after hospital admission via the emergency department using an opportunistic observational study design. This was conducted using postal questionnaires that were sent to participants recruited to the multi-centre pain solutions in the emergency setting study. Patients with prior chronic pain states or opioid use were not studied. Questionnaires included the EQ5D, the Brief Pain Inventory and the Hospital Anxiety and Depression scale. Overall, 141 out of 286 (49% 95%CI 44-56%) patients were included in this follow-up study. Participants presenting with trauma were more likely to develop persistent pain than those presenting with abdominal pain, 45 out of 64 (70%) vs. 24 out of 77 (31%); 95%CI 24-54%, p < 0.001. There were no statistically significant associations between persistent pain and analgesic modality during hospital admission, age or sex. Across both abdominal pain and traumatic injury groups, participants with persistent pain had lower EQ5D mobility scores, worse overall health and higher anxiety and depression scores (p < 0.05). In the abdominal pain group, 13 out of 50 (26%) patients using patient-controlled analgesia developed persistent pain vs. 11 out of 27 (41%) of those with usual treatment; 95%CI for difference (control - patient-controlled analgesia) -8 to 39%, p = 0.183. Acute pain scores at the time of hospital admission were higher in participants who developed persistent pain; 95%CI 0.7-23.6, p = 0.039. For traumatic pain, 25 out of 35 (71%) patients given patient-controlled analgesia developed persistent pain vs. 20 out of 29 (69%) patients with usual treatment; 95%CI -30 to 24%, p = 0.830. Persistent pain is common 6 months after hospital admission, particularly following trauma. The study findings suggest that it may be possible to reduce persistent pain (at least in patients with abdominal pain) by delivering better acute pain management. Further research is needed to confirm this hypothesis.
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Affiliation(s)
- M Rockett
- Anaesthesia and Pain Medicine, Plymouth University Hospitals NHS Trust, Plymouth, UK
| | - S Creanor
- Clinical Trials and Medical Statistics, University of Plymouth, UK
| | - R Squire
- Plymouth University Hospitals NHS Trust, Plymouth, UK
| | - A Barton
- NIHR Research Design Service South West, London, UK
| | - J Benger
- Emergency Care, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | | | - P Ewings
- NIHR Research Design Service South West, London, UK
| | - V Eyre
- Re:Cognition Health Ltd, Plymouth, UK
| | - J E Smith
- Emergency Medicine, Plymouth University Hospitals NHS Trust, Plymouth, UK
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23
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Winstanley M, Smith JE, Wright C. Catastrophic haemorrhage in military major trauma patients: a retrospective database analysis of haemostatic agents used on the battlefield. J ROY ARMY MED CORPS 2018; 165:405-409. [DOI: 10.1136/jramc-2018-001031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/19/2018] [Accepted: 08/20/2018] [Indexed: 11/04/2022]
Abstract
ObjectivesCatastrophic haemorrhage is a leading cause of morbidity and mortality in trauma, in both military and civilian settings. There are numerous studies looking at the effectiveness of different haemostatic agents in the laboratory but few in a clinical setting. This study analyses the use of haemostatic dressings used in patients injured on the battlefield and their association with survival.MethodA retrospective database review was undertaken using the UK Joint Theatre Trauma Registry from 2003 to 2014, during combat operations in Iraq and Afghanistan. Data included patient demographics, the use of haemostatic dressings, New Injury Severity Score (NISS) and patient outcome.ResultsOf 3792 cases, a haemostatic dressing was applied in 317 (either Celox, Hemcon or Quickclot). When comparing patients who had a haemostatic dressing applied versus no haemostatic agent, there was a 7% improvement in survival. Celox was the only individual haemostatic dressing that was associated with a statistically significant improvement in survival, which was most apparent in the more severely injured (NISS 36–75).ConclusionWe have shown an association between use of haemostatic agents and improved survival, mostly in those with more severe injuries, which is particularly evident in those administered Celox. This supports the continued use of haemostatic agents as part of initial haemorrhage control for patients injured in conflict and suggests that civilian organisations that may need to deal with patients with similar injury patterns should consider their use and implementation.
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Houlberg K, O'Brien D, Smith JE. Experience of the medical audit form on Op TRENTON 4. BMJ Mil Health 2018; 167:369. [PMID: 29804096 DOI: 10.1136/jramc-2018-000964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 11/04/2022]
Affiliation(s)
| | - D O'Brien
- Institute of Naval Medicine, Hampshire, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK.,Emergency Department, Derriford Hospital, Plymouth, UK
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25
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Khan M, Jeyanathan J, Smith JE. Novel use for the abdominal tourniquet in the management of postpartum haemorrhage. J ROY ARMY MED CORPS 2018; 164:463. [PMID: 29626141 DOI: 10.1136/jramc-2018-000953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Mansoor Khan
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - J Jeyanathan
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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26
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Cook AD, Lee MC, Saleh R, Khiew HW, Christensen AD, Achuthan A, Fleetwood AJ, Lacey DC, Smith JE, Förster I, Hamilton JA. TNF and granulocyte macrophage-colony stimulating factor interdependence mediates inflammation via CCL17. JCI Insight 2018; 3:99249. [PMID: 29563337 DOI: 10.1172/jci.insight.99249] [Citation(s) in RCA: 32] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 02/20/2018] [Indexed: 12/15/2022] Open
Abstract
TNF and granulocyte macrophage-colony stimulating factor (GM-CSF) have proinflammatory activity and both contribute, for example, to rheumatoid arthritis pathogenesis. We previously identified a new GM-CSF→JMJD3 demethylase→interferon regulatory factor 4 (IRF4)→CCL17 pathway that is active in monocytes/macrophages in vitro and important for inflammatory pain, as well as for arthritic pain and disease. Here we provide evidence for a nexus between TNF and this pathway, and for TNF and GM-CSF interdependency. We report that the initiation of zymosan-induced inflammatory pain and zymosan-induced arthritic pain and disease are TNF dependent. Once arthritic pain and disease are established, blockade of GM-CSF or CCL17, but not of TNF, is still able to ameliorate them. TNF is required for GM-CSF-driven inflammatory pain and for initiation of GM-CSF-driven arthritic pain and disease, but not once they are established. TNF-driven inflammatory pain and TNF-driven arthritic pain and disease are dependent on GM-CSF and mechanistically require the same downstream pathway involving GM-CSF→CCL17 formation via JMJD3-regulated IRF4 production, indicating that GM-CSF and CCL17 can mediate some of the proinflammatory and algesic actions of TNF. Given we found that TNF appears important only early in arthritic pain and disease progression, targeting a downstream mediator, such as CCL17, which appears to act throughout the course of disease, could be effective at ameliorating chronic inflammatory conditions where TNF is implicated.
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Affiliation(s)
- Andrew D Cook
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Ming-Chin Lee
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Reem Saleh
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Hsu-Wei Khiew
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Anne D Christensen
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Adrian Achuthan
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Andrew J Fleetwood
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Derek C Lacey
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Julia E Smith
- Cytokine, Chemokine and Complement DPU, Immunoinflammation TA, GSK Medicines Research Centre, Stevenage, Hertfordshire, United Kingdom
| | - Irmgard Förster
- Immunology and Environment, Life and Medical Sciences Institute University of Bonn, Bonn, Germany
| | - John A Hamilton
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
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27
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Vassallo J, Horne S, Smith JE. Triage and the Modified Physiological Triage Tool-24 (MPTT-24). BMJ Mil Health 2018; 166:33-36. [PMID: 29301857 DOI: 10.1136/jramc-2017-000878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/17/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 11/03/2022]
Abstract
Major incidents occur on a regular basis. So far in 2017, England has witnessed five terrorism-related major incidents, resulting in approximately 40 fatalities and 400 injured. Triage is a key principle in the effective management of a major incident and involves prioritising patients on the basis of their clinical acuity. This paper describes the limitations associated with existing methods of primary major incident triage and the process of developing a new and improved triage tool-the Modified Physiological Triage Tool-24 (MPTT-24). Whilst the MPTT-24 is likely to be the optimum physiological method for primary major incident triage, it needs to be accompanied by an appropriate secondary triage process. The existing UK military and civilian secondary triage tool, the Triage Sort, is described, which offers little advantage over primary methods for identifying patients who require life-saving intervention. Further research is required to identify the optimum method of secondary triage.
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Affiliation(s)
- James Vassallo
- Division of Emergency Medicine, University of Cape Town, South Africa .,Institute of Naval Medicine, Hampshire, UK
| | - S Horne
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - J E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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28
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Vassallo J, Smith JE, Wallis LA. Major incident triage and the implementation of a new triage tool, the MPTT-24. J ROY ARMY MED CORPS 2017; 164:103-106. [PMID: 29055894 PMCID: PMC5969370 DOI: 10.1136/jramc-2017-000819] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 11/12/2022]
Abstract
Introduction The Modified Physiological Triage Tool (MPTT) is a recently developed primary triage tool and in comparison with existing tools demonstrates the greatest sensitivity at predicting need for life-saving intervention (LSI) within both military and civilian populations. To improve its applicability, we proposed to increase the upper respiratory rate (RR) threshold to 24 breaths per minute (bpm) to produce the MPTT-24. Our aim was to conduct a feasibility analysis of the proposed MPTT-24, comparing its performance with the existing UK Military Sieve. Method A retrospective review of the Joint Theatre Trauma Registry (JTTR) and Trauma Audit Research Network (TARN) databases was performed for all adult (>18 years) patients presenting between 2006–2013 (JTTR) and 2014 (TARN). Patients were defined as priority one (P1) if they received one or more LSIs. Using first recorded hospital RR in isolation, sensitivity and specificity of the ≥24 bpm threshold was compared with the existing threshold (≥22 bpm) at predicting P1 status. Patients were then categorised as P1 or not-P1 by the MPTT, MPTT-24 and the UK Military Sieve. Results The MPTT and MPTT-24 outperformed existing UK methods of triage with a statistically significant (p<0.001) increase in sensitivity of between 25.5% and 29.5%. In both populations, the MPTT-24 demonstrated an absolute reduction in sensitivity with an increase in specificity when compared with the MPTT. A statistically significant difference was observed between the MPTT and MPTT-24 in the way they categorised TARN and JTTR cases as P1 (p<0.001). Conclusions When compared with the existing MPTT, the MPTT-24 allows for a more rapid triage assessment. Both continue to outperform existing methods of primary major incident triage and within the military setting, the slight increase in undertriage is offset by a reduction in overtriage. We recommend that the MPTT-24 be considered as a replacement to the existing UK Military Sieve.
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Affiliation(s)
- James Vassallo
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Naval Medicine, Gosport, UK
| | - J E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Birmingham, UK
| | - L A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Barnard EBG, Hunt PAF, Lewis PEH, Smith JE. The outcome of patients in traumatic cardiac arrest presenting to deployed military medical treatment facilities: data from the UK Joint Theatre Trauma Registry. J ROY ARMY MED CORPS 2017; 164:150-154. [DOI: 10.1136/jramc-2017-000818] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/20/2017] [Accepted: 08/22/2017] [Indexed: 11/04/2022]
Abstract
BackgroundThe UK military was continuously engaged in armed conflict in Iraq and Afghanistan between 2003 and 2014, resulting in 629 UK fatalities. Traumatic cardiac arrest (TCA) is a precursor to traumatic death, but data on military outcomes are limited. In order to better inform military treatment protocols, the aim of this study was to define the epidemiology of TCA in the military population with a particular focus on survival rates and injury patterns.MethodsA retrospective database analysis of the UK Joint Theatre Trauma Registry was undertaken. Patients who were transported to a UK deployed hospital between 2003 and 2014 and suffered TCA were included. Those patients injured by asphyxiation, electrocution, burns without other significant trauma and drowning were excluded. Data included mechanism of injury, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) for each body region and survival to deployed (Role 3) field hospital discharge.Results424 TCA patients were identified during the study period; median age was 23 years, with a median ISS of 45. The most common mechanism of injury was explosive (55.7%), followed by gunshot wound (38.9%), road traffic collision (3.5%), crush (1.7%) and fall (0.2%). 45 patients (10.6% (95% CI 8.0% to 13.9%)) survived to deployed (Role 3) hospital discharge. The most prevalent body region with a severe to maximum AIS injury was the head, followed by the lower limbs, thorax and abdomen. Haemorrhage secondary to abdominal and lower limb injury was associated with survival; traumatic brain injury was associated with death.ConclusionsThis study has shown that short-term survival from TCA in a military population is 10.6%. With appropriate and aggressive early management, although unlikely, survival is still potentially possible in military patients who suffer traumatic cardiac arrest.
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30
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Vassallo J, Horne S, Smith JE, Wallis LA. The prospective validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to major incident triage. J ROY ARMY MED CORPS 2017; 163:383-387. [DOI: 10.1136/jramc-2017-000771] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/06/2017] [Accepted: 05/21/2017] [Indexed: 11/04/2022]
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31
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Pritchard C, Smith JE, Creanor S, Squire R, Barton A, Benger J, Cocking L, Ewings P, Rockett M. The cost-effectiveness of patient-controlled analgesia vs. standard care in patients presenting to the Emergency Department in pain, who are subsequently admitted to hospital. Anaesthesia 2017; 72:953-960. [PMID: 28547753 DOI: 10.1111/anae.13932] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2017] [Indexed: 11/30/2022]
Abstract
The clinical effectiveness of patient-controlled analgesia has been demonstrated in a variety of settings. However, patient-controlled analgesia is rarely utilised in the Emergency Department. The aim of this study was to compare the cost-effectiveness of patient-controlled analgesia vs. standard care in participants admitted to hospital from the Emergency Department with pain due to traumatic injury or non-traumatic abdominal pain. Pain scores were measured hourly for 12 h using a visual analogue scale. Cost-effectiveness was measured as the additional cost per hour in moderate to severe pain avoided by using patient-controlled analgesia rather than standard care (the incremental cost-effectiveness ratio). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. The cost per hour in moderate or severe pain averted was estimated as £24.77 (€29.05, US$30.80) (bootstrap estimated 95%CI £8.72 to £89.17) for participants suffering pain from traumatic injuries and £15.17 (€17.79, US$18.86) (bootstrap estimate 95%CI £9.03 to £46.00) for participants with non-traumatic abdominal pain. Overall costs were higher with patient-controlled analgesia than standard care in both groups: pain from traumatic injuries incurred an additional £18.58 (€21.79 US$23.10) (95%CI £15.81 to £21.35) per 12 h; and non-traumatic abdominal pain an additional £20.18 (€23.67 US$25.09) (95%CI £19.45 to £20.84) per 12 h.
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Affiliation(s)
- C Pritchard
- NIHR Research Design Service, South West, UK
| | - J E Smith
- Department of Anaesthesia, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
| | - S Creanor
- Department of Medical Statistics, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - R Squire
- Emergency Department, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
| | - A Barton
- NIHR Research Design Service, South West, UK
| | - J Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - L Cocking
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - P Ewings
- NIHR Research Design Service, South West, UK
| | - M Rockett
- Department of Anaesthesia, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
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32
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Barnard EB, Smith JE, Manning JE, Rall JM, Cox JM, Bebarta VS, Ross JD. A DESCRIPTIVE PARADIGM OF ESCALATING ENDOVASCULAR INTERVENTION FOR THE MANAGEMENT OF TRAUMATIC CARDIAC ARREST IN A SWINE MODEL OF NON-COMPRESSIBLE TORSO HAEMORRHAGE. Arch Emerg Med 2016. [DOI: 10.1136/emermed-2016-206402.5] [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: 11/03/2022]
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33
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Barnard EB, Smith JE, Manning JE, Rall JM, Cox JM, Bebarta VS, Ross JD. SELECTIVE AORTIC ARCH PERFUSION FOR THE REVERSAL OF HAEMORRHAGE-INDUCED TRAUMATIC CARDIAC ARREST IN A SWINE MODEL OF NON-COMPRESSIBLE TORSO HAEMORRHAGE. Arch Emerg Med 2016. [DOI: 10.1136/emermed-2016-206402.1] [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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Smith JE, Squire R, Pritchard C, Ewings P, Barton A, Rockett M, Creanor S, Hayward C, Eyre V, Cocking L, Benger J. THE COST-EFFECTIVENESS OF PATIENT CONTROLLED ANALGESIA VERSUS ROUTINE CARE IN PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT IN PAIN, WHO ARE SUBSEQUENTLY ADMITTED TO HOSPITAL. Arch Emerg Med 2016. [DOI: 10.1136/emermed-2016-206402.19] [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: 11/04/2022]
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Abstract
Aim Major trauma (MT) has traditionally been viewed as a disease of young men caused by high-energy transfer mechanisms of injury, which has been reflected in the configuration of MT services. With ageing populations in Western societies, it is anticipated that the elderly will comprise an increasing proportion of the MT workload. The aim of this study was to describe changes in the demographics of MT in a developed Western health system over the last 20 years. Methods The Trauma Audit Research Network (TARN) database was interrogated to identify all cases of MT (injury severity score >15) between 1990 and the end of 2013. Age at presentation, gender, mechanism of injury and use of CT were recorded. For convenience, cases were categorised by age groups of 25 years and by common mechanisms of injury. Longitudinal changes each year were recorded. Results Profound changes in the demographics of recorded MT were observed. In 1990, the mean age of MT patients within the TARN database was 36.1, the largest age group suffering MT was 0–24 years (39.3%), the most common causative mechanism was road traffic collision (59.1%), 72.7% were male and 33.6% underwent CT. By 2013, mean age had increased to 53.8 years, the single largest age group was 25–50 years (27.1%), closely followed by those >75 years (26.9%), the most common mechanism was low falls (39.1%), 68.3% were male and 86.8% underwent CT. Conclusions This study suggests that the MT population identified in the UK is becoming more elderly, and the predominant mechanism that precipitates MT is a fall from <2 m. Significant improvements in outcomes from MT may be expected if services targeting the specific needs of the elderly are developed within MT centres.
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Affiliation(s)
- A Kehoe
- Emergency Department, Derriford Hospital, Plymouth, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - J E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Birmingham, UK
| | - A Edwards
- Trauma Audit Research Network (TARN), University of Manchester, Hope Hospital, Salford, UK
| | - D Yates
- Trauma Audit Research Network (TARN), University of Manchester, Hope Hospital, Salford, UK
| | - F Lecky
- Trauma Audit Research Network (TARN), University of Manchester, Hope Hospital, Salford, UK EMRiS Group, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
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Kyle T, le Clerc S, Thomas A, Greaves I, Whittaker V, Smith JE. The success of battlefield surgical airway insertion in severely injured military patients: a UK perspective. J ROY ARMY MED CORPS 2016; 162:460-464. [DOI: 10.1136/jramc-2016-000637] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/14/2016] [Accepted: 04/17/2016] [Indexed: 11/03/2022]
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Smith JE, Withnall RDJ, Rickard RF, Lamb D, Sitch A, Hodgetts TJ. A pilot study to evaluate the utility of live training (LIVEX) in the operational preparedness of UK military trauma teams. Postgrad Med J 2016; 92:697-700. [DOI: 10.1136/postgradmedj-2015-133585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 12/22/2015] [Accepted: 04/17/2016] [Indexed: 11/04/2022]
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Kehoe A, Smith JE, Bouamra O, Edwards A, Yates D, Lecky F. Older patients with traumatic brain injury present with a higher GCS score than younger patients for a given severity of injury. Emerg Med J 2016; 33:381-5. [DOI: 10.1136/emermed-2015-205180] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/29/2015] [Indexed: 11/03/2022]
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Smith JE, Le Clerc S, Hunt PAF. Challenging the dogma of traumatic cardiac arrest management: a military perspective. Emerg Med J 2015; 32:955-60. [PMID: 26493124 DOI: 10.1136/emermed-2015-204684] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 01/23/2015] [Accepted: 09/28/2015] [Indexed: 11/04/2022]
Abstract
Attempts to resuscitate patients in traumatic cardiac arrest (TCA) have, in the past, been viewed as futile. However, reported outcomes from TCA in the past five years, particularly from military series, are improving. The pathophysiology of TCA is different to medical causes of cardiac arrest, and therefore, treatment priorities may also need to be different. This article reviews recent literature describing the pathophysiology of TCA and describes how the military has challenged the assumption that outcome is universally poor in these patients.
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Affiliation(s)
- J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK Emergency Department, Derriford Hospital, Plymouth, UK
| | - S Le Clerc
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK Emergency Department, James Cook University Hospital, Middlesbrough, UK
| | - P A F Hunt
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK Emergency Department, James Cook University Hospital, Middlesbrough, UK
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Lay E, Nutland S, Smith JE, Hiles I, Smith RAG, Seilly DJ, Buchberger A, Schwaeble W, Lachmann PJ. Complotype affects the extent of down-regulation by Factor I of the C3b feedback cycle in vitro. Clin Exp Immunol 2015; 181:314-22. [PMID: 25124117 DOI: 10.1111/cei.12437] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2014] [Indexed: 01/12/2023] Open
Abstract
Sera from a large panel of normal subjects were typed for three common polymorphisms, one in C3 (R102G) and two in Factor H (V62I and Y402H), that influence predisposition to age-related macular degeneration and to some forms of kidney disease. Three groups of sera were tested; those that were homozygous for the three risk alleles; those that were heterozygous for all three; and those homozygous for the low-risk alleles. These groups vary in their response to the addition of exogenous Factor I when the alternative complement pathway is activated by zymosan. Both the reduction in the maximum amount of iC3b formed and the rate at which the iC3b is converted to C3dg are affected. For both reactions the at-risk complotype requires higher doses of Factor I to produce similar down-regulation. Because iC3b reacting with the complement receptor CR3 is a major mechanism by which complement activation gives rise to inflammation, the breakdown of iC3b to C3dg can be seen to have major significance for reducing complement-induced inflammation. These findings demonstrate for the first time that sera from subjects with different complement alleles behave as predicted in an in-vitro assay of the down-regulation of the alternative complement pathway by increasing the concentration of Factor I. These results support the hypothesis that exogenous Factor I may be a valuable therapeutic aid for down-regulating hyperactivity of the C3b feedback cycle, thereby providing a treatment for age-related macular degeneration and other inflammatory diseases of later life.
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Affiliation(s)
- E Lay
- Department of Veterinary Medicine, University of Cambridge, UK
| | - S Nutland
- Cambridge Bioresource, Cambridge University and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J E Smith
- Immuno-inflammation Therapy Area, GlaxoSmithKline R&D, Stevenage, Hertfordshire, UK
| | - I Hiles
- Biopharm-Discovery, GlaxoSmithKline R&D, Stevenage, Hertfordshire, UK
| | - R A G Smith
- Protein Therapeutics Laboratory, MRC Centre for Transplantation, King's College London, Guy's Hospital, London, UK
| | - D J Seilly
- Department of Veterinary Medicine, University of Cambridge, UK
| | - A Buchberger
- Department of Infection, University of Leicester, Leicester, UK
| | - W Schwaeble
- Department of Infection, University of Leicester, Leicester, UK
| | - P J Lachmann
- Department of Veterinary Medicine, University of Cambridge, UK
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Hillman CM, Rickard A, Rawlins M, Smith JE. Paediatric traumatic cardiac arrest: data from the Joint Theatre Trauma Registry. J ROY ARMY MED CORPS 2015; 162:276-9. [PMID: 26116000 DOI: 10.1136/jramc-2015-000464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 05/01/2015] [Accepted: 06/06/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Traumatic cardiac arrest (TCA) in children is associated with a low probability of survival and poor neurological outcome in survivors. Since 2003, over 600 seriously injured local national children have been treated at deployed UK military medical treatment facilities during the Iraq and Afghanistan conflicts. A number of these were in cardiac arrest after sustaining traumatic injuries. This study defined outcomes from paediatric TCA in this cohort. METHODS A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry. This includes UK military, coalition military, civilians and local security forces personnel who prompted trauma team activation. All children in this series were local nationals. Patients aged less than 18 years who presented between January 2003 and April 2014, and who underwent cardiopulmonary resuscitation, were included. RESULTS 27 children with TCA were included. Four children survived to discharge from the medical treatment facility (14.8%), though limited data are available regarding the long-term neurological outcome in these patients. CONCLUSIONS This study demonstrates that the outcomes for paediatric TCA in our military field hospitals were similar to other paediatric civilian and adult military studies, despite patients being injured by severe blast injuries. Further work is needed to define the optimal management of paediatric TCA.
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Affiliation(s)
| | - A Rickard
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - M Rawlins
- Clinical Information & Exploitation Team, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
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Smith JE, Smith SRC, Hill G. The UK maritime Role 3 medical treatment facility: the Primary Casualty Receiving Facility, RFA ARGUS. ACTA ACUST UNITED AC 2015. [DOI: 10.1136/jrnms-101-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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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James RH, Henning DCW, Smith JE. The use of impedance threshold devices in spontaneously breathing, hypotensive trauma patients. Trauma 2015. [DOI: 10.1177/1460408614539146] [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: 11/15/2022]
Abstract
Impedance threshold devices are a novel therapeutic option to increase blood pressure in the spontaneously breathing, hypotensive, trauma patient. They have multiple potential mechanisms of action. The most important is their ability to induce a more negative intrathoracic pressure during inspiration. They achieve this by the presence of a series of valves. These valves only open once the patient has generated a more negative intrathoracic pressure than is normally required for inspiration to occur. This negative intrathoracic pressure is thought to increase venous return and therefore cardiac output and subsequently blood pressure. This narrative review examines the evidence pertaining to the use of these devices in spontaneously breathing, hypotensive, trauma patients. While the literature supports the ability of these devices to increase systolic blood pressure in both animal and human models of hypotension, and more recently in patients with true pathological hypotension, potential flaws are discussed, and several key questions that have not been addressed by studies to date are highlighted. Notwithstanding these problems, impedance threshold devices may have a role in hypotensive trauma patients, particularly during the pre-hospital phase of care when available resources limit treatment options. Further work is required to prove both their clinical effectiveness and safety.
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Affiliation(s)
- RH James
- Emergency Department, Derriford Hospital, Plymouth, Devon, UK
| | - DCW Henning
- Emergency Department, Derriford Hospital, Plymouth, Devon, UK
| | - JE Smith
- Emergency Department, Derriford Hospital, Plymouth, Devon, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
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Abstract
An immediate, effective team response is needed in order to properly cater to the needs of trauma patients. This paper aims to review some of the strategies that can be implemented in Emergency Departments to reduce errors and improve decision-making in major trauma. It focuses on the phase prior to the patient’s arrival, and in the first few minutes afterwards – as there is evidence that an organised response at this point creates the ideal conditions for all subsequent activity, such as transfer of the patient for further imaging and the requirement for emergency surgery.
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Affiliation(s)
- S Horne
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Birmingham, UK
| | - JE Smith
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Birmingham, UK
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Smith JE, Smith SRC, Hill G. The UK maritime Role 3 medical treatment facility: the Primary Casualty Receiving Facility, RFA ARGUS. J R Nav Med Serv 2015; 101:3-5. [PMID: 26292383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Osborne M, Smith JE. Action Stations! 100 years of trauma care on maritime and amphibious operations in the Royal Navy. J R Nav Med Serv 2015; 101:7-12. [PMID: 26292385] [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: 06/04/2023]
Abstract
Over the past century trauma care within the Royal Navy (RN) has evolved; wartime experiences and military medical research have combined to allow significant improvement in the care of casualties. This article describes the key maritime and amphibious operations that have seen the Royal Navy Medical Service (RNMS) deliver high levels of support to wherever the Naval Service has deployed in the last 100 years. Key advancements in which progress has led to improved outcomes for injured personnel are highlighted--the control and treatment of blood loss, wound care, and the prevention and management of organ failure with optimal resuscitation. Historians often point out how slowly military medicine progressed for the first few thousand years of its recorded history, and how quickly it has progressed in the last century. This reflective article will show how the RNMS has been an integral part of that story, and how the lessons learnt by our predecessors have shaped our modern day doctrine surrounding trauma care.
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Kruidenier L, Chung CW, Cheng Z, Liddle J, Che K, Joberty G, Bantscheff M, Bountra C, Bridges A, Diallo H, Eberhard D, Hutchinson S, Jones E, Katso R, Leveridge M, Mander PK, Mosley J, Ramirez-Molina C, Rowland P, Schofield CJ, Sheppard RJ, Smith JE, Swales C, Tanner R, Thomas P, Tumber A, Drewes G, Oppermann U, Patel DJ, Lee K, Wilson DM. Kruidenier et al. reply. Nature 2014; 514:E2. [PMID: 25279927 DOI: 10.1038/nature13689] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Laurens Kruidenier
- Epinova DPU, Immuno-Inflammation Therapy Area, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Chun-wa Chung
- Platform Technology and Science, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Zhongjun Cheng
- Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, USA
| | - John Liddle
- Epinova DPU, Immuno-Inflammation Therapy Area, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - KaHing Che
- 1] Structural Genomics Consortium, University of Oxford, Old Road Campus, Roosevelt Drive, Headington OX3 7DQ, UK [2] Botnar Research Centre, NIHR Biomedical Research Unit, University of Oxford OX3 7LD, UK
| | - Gerard Joberty
- Cellzome AG, Meyerhofstrasse 1, 69117 Heidelberg, Germany
| | | | - Chas Bountra
- Structural Genomics Consortium, University of Oxford, Old Road Campus, Roosevelt Drive, Headington OX3 7DQ, UK
| | - Angela Bridges
- Platform Technology and Science, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Hawa Diallo
- Epinova DPU, Immuno-Inflammation Therapy Area, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Dirk Eberhard
- Cellzome AG, Meyerhofstrasse 1, 69117 Heidelberg, Germany
| | - Sue Hutchinson
- Platform Technology and Science, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Emma Jones
- Platform Technology and Science, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Roy Katso
- Platform Technology and Science, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Melanie Leveridge
- Platform Technology and Science, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Palwinder K Mander
- Epinova DPU, Immuno-Inflammation Therapy Area, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Julie Mosley
- Platform Technology and Science, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Cesar Ramirez-Molina
- Epinova DPU, Immuno-Inflammation Therapy Area, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Paul Rowland
- Platform Technology and Science, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Christopher J Schofield
- Structural Genomics Consortium, University of Oxford, Old Road Campus, Roosevelt Drive, Headington OX3 7DQ, UK
| | - Robert J Sheppard
- Epinova DPU, Immuno-Inflammation Therapy Area, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Julia E Smith
- Epinova DPU, Immuno-Inflammation Therapy Area, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Catherine Swales
- Botnar Research Centre, NIHR Biomedical Research Unit, University of Oxford OX3 7LD, UK
| | - Robert Tanner
- Platform Technology and Science, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Pamela Thomas
- Platform Technology and Science, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
| | - Anthony Tumber
- Structural Genomics Consortium, University of Oxford, Old Road Campus, Roosevelt Drive, Headington OX3 7DQ, UK
| | - Gerard Drewes
- Cellzome AG, Meyerhofstrasse 1, 69117 Heidelberg, Germany
| | - Udo Oppermann
- 1] Structural Genomics Consortium, University of Oxford, Old Road Campus, Roosevelt Drive, Headington OX3 7DQ, UK [2] Botnar Research Centre, NIHR Biomedical Research Unit, University of Oxford OX3 7LD, UK
| | - Dinshaw J Patel
- Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, USA
| | - Kevin Lee
- 1] Epinova DPU, Immuno-Inflammation Therapy Area, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK [2] Pfizer, Biotherapeutics R&D, 200 Cambridgepark Drive, Cambridge, Massachusetts 02140, USA
| | - David M Wilson
- Epinova DPU, Immuno-Inflammation Therapy Area, GlaxoSmithKline R&D, Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, UK
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Kehoe A, Rennie S, Smith JE. Glasgow Coma Scale is unreliable for the prediction of severe head injury in elderly trauma patients. Emerg Med J 2014; 32:613-5. [PMID: 25280479 DOI: 10.1136/emermed-2013-203488] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [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: 12/07/2013] [Accepted: 09/15/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVES AND BACKGROUND Elderly patients comprise an ever-increasing proportion of major trauma patients. The presenting GCS in elderly patients with traumatic brain injury (TBI) may not reflect the severity of injury as accurately as it does in the younger patient population. However, GCS is often used as part of the decision tool to define the population transferred directly to a major trauma centre. The aim of this study was to explore the relationship between age and presenting GCS in patients with isolated TBI. METHODS A retrospective database review was undertaken using the Trauma Audit and Research Network database. All patients presenting to Derriford Hospital, Plymouth, between 1 January 2009 and 31 May 2014 with isolated TBI were included. Demographic, mechanistic, physiological, resource use and outcome data were collected. Abbreviated injury scale (AIS) was recorded for all patients. Patients were categorised into those older and younger than 65 years on presentation. Distribution of GCS, categorised into severe (GCS 3-8), moderate (GCS 9-12) and mild TBI (13-15), was compared between the age groups. Median GCS at each AIS level was also compared. RESULTS The distribution of GCS differed between young and old patients with TBI (22.1% vs 9.8% had a GCS 3-8, respectively) despite a higher burden of anatomical injury in the elderly group. Presenting GCS was higher in the elderly at each level of AIS. The difference was more apparent in the presence of more severe injury (AIS 5). CONCLUSIONS Elderly patients who have sustained isolated severe TBI may present with a higher GCS than younger patients. Triage tools using GCS may need to be modified and validated for use in elderly patients with TBI.
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Affiliation(s)
- A Kehoe
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - S Rennie
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - J E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
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Barnard EBG, Moy RJ, Kehoe AD, Bebarta VS, Smith JE. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J 2014; 32:449-52. [PMID: 24963149 DOI: 10.1136/emermed-2014-203740] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [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: 02/27/2014] [Accepted: 05/27/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intraosseous (IO) drug infusion has been reported to have similar pharmacokinetics to intravenous (IV) infusion. In military and civilian trauma, the IO route is often used to obtain rapid and reliable parenteral access for drug administration. Only a few case reports have described the use of IO infusion to administer drugs for rapid sequence induction of anaesthesia (RSI). OBJECTIVE We aimed to assess the feasibility of the administration of RSI drugs via an IO catheter in a prospective observational study. METHODS A prospective observational study was undertaken at a combat hospital in Afghanistan. A validated data form was used to record the use of IO drugs for RSI by the prehospital, physician-led Medical Emergency Response Team (MERT), and by inhospital physicians. Data were captured between January and May 2012 by interview with MERT physicians and inhospital physicians directly after RSI. The primary outcome measure was the success rate of first-pass intubation with direct laryngoscopy. RESULTS 34 trauma patients (29 MERT and 5 inhospital) underwent RSI with IO drug administration. The median age was 24 years and median injury severity score 25; all were male. The predominant mechanism of injury was blast (n=24), followed by penetrating (n=6), blunt (n=3) and burn (n=1). First-pass intubation success rate was 97% (95% CI 91% to 100%). A Cormack-Lehane grade 1 view, by direct laryngoscopy, was obtained at first look in 91% (95% CI 81% to 100%) of patients. CONCLUSIONS In this prospective, observational study, IO drug administration was successfully used for trauma RSI, with a comparable first pass intubation success than published studies describing the IV route. TRIAL REGISTRATION NUMBER RCDM/Res/Audit/1036/12/0162.
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Affiliation(s)
- E B G Barnard
- Air Force En Route Care Research Center, San Antonio Military Medical Center, San Antonio, Texas, USA Institute of Naval Medicine, Alverstoke, UK
| | - R J Moy
- Emergency Department, Glasgow Royal Infirmary, Glasgow, UK
| | - A D Kehoe
- Emergency Department, Derriford Hospital, UK
| | - V S Bebarta
- Air Force En Route Care Research Center, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - J E Smith
- Emergency Department, Derriford Hospital, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
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