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Ferry AV, Wereski R, Marshall L, Strachan FE, Schulberg SD, Bularga A, Chapman AR, Lee KK, Anand A, Mills NL. Exploring adherence to an early rule-out pathway for myocardial infarction in the emergency department using mixed-methods. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1347] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Incorporating a high-sensitivity cardiac troponin assay into a care pathway for the assessment of suspected acute coronary syndrome has enabled myocardial infarction to be ruled out earlier.
Purpose
Using mixed methods, we explored adherence to an early rule-out pathway in the HiSTORIC (High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction) randomised controlled trial.
Methods
In 16,972 consecutive patients we evaluated clinician adherence to an early rule-out pathway for the assessment of suspected acute coronary syndrome. Adherence was defined in patients with presentation cardiac troponin I concentrations <5ng/L and symptom onset >2 hours from presentation without serial troponin testing (type 1 adherence); presentation troponin <5ng/L and symptom onset ≤2 hours from presentation with serial testing (type 2 adherence); or presentation troponin between 5ng/L and sex-specific 99th centile with serial testing (type 3 adherence). Semi-structured interviews were conducted with 23 clinicians to aid interpretation of the quantitative analysis. Qualitative data were coded and organized into themes.
Results
In patients with troponin <5ng/L presenting >2hr from symptom onset, adherence was achieved in 81% of patients. In patients presenting ≤2hr from symptom onset, 35% of patients had a second troponin test. In patients with an initial troponin concentration between 5ng/L and the 99th centile, 65% of patients had a second troponin test. Compared to patients managed by clinicians who were adherent to the pathway, patients with troponin over-testing (type 1 non-adherence) were more likely to be older (mean age 52±16 years versus 58±14, P<0.001) and have a history of coronary disease (11% versus 27%, P<0.001). In contrast, patients with under testing (type 2 non-adherence) tended to be younger (mean age 49±16 versus 63±15, P<0.001), female (50% versus 37%, P<0.001) and have lower presentation troponin levels (median concentration 1.0ng/L IQR 1.0 to 2.0, versus 5.0ng/L IQR 2.0–10.0) compared to those in whom testing was performed according to pathway recommendations. Semi-structured interview data revealed how pathway adherence was influenced by five main themes: guideline characteristics, patient characteristics, the healthcare practitioner, the healthcare system and scientific evidence. Clear visual pathway layout was fundamental in achieving optimal adherence. Strong clinical suspicion of acute coronary syndrome promoted repeat troponin testing and deviation from the pathway was felt to be justifiable by more senior clinicians.
Conclusion
This analysis revealed successful implementation of the early rule-out pathway with interview data aiding interpretation of trial data. Younger patients with lower troponin concentrations were less likely to receive pathway recommended serial troponin testing. Clinical judgement is one of the main reasons for discontinuation of pathway recommendations.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): British Heart Foundation
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Affiliation(s)
- A V Ferry
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - R Wereski
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - L Marshall
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - F E Strachan
- Usher Institute of Population Health Sciences and Informatics , Edinburgh , United Kingdom
| | - S D Schulberg
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - A Bularga
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - A R Chapman
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - K K Lee
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - A Anand
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - N L Mills
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
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Doudesis D, Lee KK, Bularga A, Ferry AV, Tuck C, Anand A, Boeddinghaus J, Mueller C, Greenslade JH, Pickering JW, Than MP, Cullen L, Mills NL. Machine learning to optimise use of cardiac troponin in the diagnosis of acute myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1349] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Guidelines recommend fixed cardiac troponin thresholds for the assessment of patients with suspected acute coronary syndrome, however, performance varies in important patient groups as concentrations are influenced by age, sex and comorbidities. This limitation can be addressed using machine learning algorithms.
Methods
Machine learning algorithms were developed that integrate cardiac troponin concentrations at presentation or on serial testing with age, sex and clinical features in 10,038 consecutive emergency patients with suspected acute coronary syndrome. The primary outcome was an adjudicated diagnosis of type 1, type 4b or type 4c myocardial infarction. The best performing algorithm was selected for the CoDE-ACS (Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome) decision-support tool, and performance was externally validated in 3,035 patients pooled from three prospective studies.
Findings
CoDE-ACS had excellent discrimination and calibration using cardiac troponin at presentation (area under curve [AUC] 0.959, 95% confidence interval 0.948–0.971, Brier score 0.040), in the pooled external validation cohort. At presentation, the rule-out score identified 62.1% (1,885/3,035) of all patients as low-probability of myocardial infarction with a 99.5% (99.1–99.7%) negative predictive value and 97.0% (96.3–97.6%) sensitivity. The rule-in score identified 8.3% (252/3,035) of patients as high-probability with an 83.7% (82.4–85.0%) positive predictive value and 98.5% (98.0–98.9%) specificity. Performance of the rule-out and rule-in scores was consistent across patient subgroups (Figure 1 and Figure 2). CoDE-ACS incorporating a second cardiac troponin measurement also had excellent discrimination and calibration (AUC 0.971 [0.962–0.980], Brier score 0.039) and refined the individualised probabilities in the 29.5% (898/3,035) of patients neither ruled-out or ruled-in at presentation to guide further investigation.
Conclusions
We developed and externally validated the CoDE-ACS decision-support tool using machine learning to aid in the diagnosis of myocardial infarction. CoDE-ACS had excellent diagnostic performance to rule-out and rule-in myocardial infarction at presentation, performed consistently across patient subgroups, and provided individualised probabilities to guide further care in those who require serial troponin measurements.
Conclusions
We developed and externally validated the CoDE-ACS decision-support tool using machine learning to aid in the diagnosis of myocardial infarction. CoDE-ACS had excellent diagnostic performance to rule-out and rule-in myocardial infarction at presentation, performed consistently across patient subgroups, and provided individualised probabilities to guide further care in those who require serial troponin measurements.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): National Institute for Health ResearchBritish Heart Foundation
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Affiliation(s)
- D Doudesis
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - K K Lee
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - A Bularga
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - A V Ferry
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - C Tuck
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - A Anand
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
| | - J Boeddinghaus
- University of Basel, Cardiovascular Research Institute Basel and Department of Cardiology , Basel , Switzerland
| | - C Mueller
- University of Basel, Cardiovascular Research Institute Basel and Department of Cardiology , Basel , Switzerland
| | - J H Greenslade
- University of Queensland, School of Medicine , Brisbane , Australia
| | - J W Pickering
- University of Otago, Christchurch Heart Institute , Christchurch , New Zealand
| | - M P Than
- Christchurch Hospital , Christchurch , New Zealand
| | - L Cullen
- University of Queensland, School of Medicine , Brisbane , Australia
| | - N L Mills
- University of Edinburgh, Centre for Cardiovascular Sciences , Edinburgh , United Kingdom
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3
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Bularga A, Kimenai DM, Taggart C, Lowry M, Wereski R, McCance K, Lee KK, Anand A, Strachan FE, Tuck C, Shah ASV, Chapman AR, Newby DE, Jenks S, Mills NL. Impact of patient selection on performance of an early rule-out pathway for myocardial infarction: from research to the real world. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1344] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Early rule-out pathways for myocardial infarction using high-sensitivity cardiac troponin are widely recommended in the assessment of patients with suspected acute coronary syndrome. Although developed in selected patients participating in research studies, these pathways are applied more widely in clinical practice where the diagnostic performance and effectiveness of these pathways may differ.
Purpose
To evaluate the performance of an early rule-out pathway for myocardial infarction using high-sensitivity cardiac troponin in selected and consecutive unselected patients with suspected acute coronary syndrome.
Methods
Presentation and serial high-sensitivity cardiac troponin I concentrations were measured in two cohorts of patients with suspected acute coronary syndrome presenting to the Emergency Departments across three acute care hospitals in Scotland. In the unselected cohort, electronic health record data were collected on consecutive patients in whom the usual care clinician measured cardiac troponin for suspected acute coronary syndrome. In the selected cohort, patients with suspected acute coronary syndrome were approached between 8am and 8pm by research staff and written informed consent obtained. In both cohorts, the performance of the High-STEACS early rule-out pathway was evaluated for an adjudicated diagnosis of myocardial infarction (type 1, type 4b or type 4c) during the index hospital admission.
Results
The unselected and selected patient cohorts comprised of 1,242 (median age 60 [interquartile range 47–75] years, 46% women) and 1,695 (median age 61 [52–73] years, 40% women) patients respectively. Myocardial infarction was diagnosed in 6% (74/1,242) and 14% (232/1,695) of patients in the unselected and selected patient cohorts respectively. More patients had myocardial infarction ruled-out in the unselected (74% [828/1,112] versus 66% [1,102/1,678]; P<0.001), with similar negative predictive value (99.9% [95% CI 99.7%-100%] versus 99.7% [95% CI 99.4%-99.0%) and sensitivity (99.3% [95% CI 97.4%-100%] versus 98.9% [95% CI 97.6%-99.9%]; Figure 1). In the selected cohort, more patients had intermediate troponin concentrations requiring serial testing (36% versus 29%) or had myocardial infarction diagnosed (34% versus 26%; P<0.001 for both). In contrast, the positive predictive value for myocardial infarction was lower in unselected patients (26.1% [95% CI 21.2%-31.4%] versus 39.9% [95% CI 35.9%-44.0%]).
Conclusion
The prevalence of myocardial infarction is lower in patients with suspected acute coronary syndrome evaluated in routine practice compared to those selected to participate in a research study. Whilst more patients have myocardial infarction accurately ruled out, the positive-predictive value in those ruled in is lower resulting in more hospital admissions with elevated cardiac troponin due to other conditions.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart FoundationMedical Research Council
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Affiliation(s)
- A Bularga
- University of Edinburgh , Edinburgh , United Kingdom
| | - D M Kimenai
- University of Edinburgh , Edinburgh , United Kingdom
| | - C Taggart
- University of Edinburgh , Edinburgh , United Kingdom
| | - M Lowry
- University of Edinburgh , Edinburgh , United Kingdom
| | - R Wereski
- University of Edinburgh , Edinburgh , United Kingdom
| | - K McCance
- University of Edinburgh, Department Clinical Biochemistry, , Edinburgh , United Kingdom
| | - K K Lee
- University of Edinburgh , Edinburgh , United Kingdom
| | - A Anand
- University of Edinburgh , Edinburgh , United Kingdom
| | - F E Strachan
- University of Edinburgh , Edinburgh , United Kingdom
| | - C Tuck
- University of Edinburgh , Edinburgh , United Kingdom
| | - A S V Shah
- London School of Hygiene and Tropical Medicine, Department of Cardiology , London , United Kingdom
| | - A R Chapman
- University of Edinburgh , Edinburgh , United Kingdom
| | - D E Newby
- University of Edinburgh , Edinburgh , United Kingdom
| | - S Jenks
- Royal Infirmary of Edinburgh, Department of Clinical Biochemistry , Edinburgh , United Kingdom
| | - N L Mills
- University of Edinburgh , Edinburgh , United Kingdom
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4
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Doudesis D, Lee KK, Anwar M, Astengo F, Newby D, Japp A, Tsanas A, Shah A, Richards M, McMurray J, Mueller C, Januzzi J, Mills N. Machine learning to aid in the diagnosis of acute heart failure in the emergency department. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1040] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
B-type natriuretic peptide (BNP) and mid-regional pro-atrial natriuretic peptide (MRproANP) testing are recommended to aid in the diagnosis of acute heart failure. However, the application of these biomarkers for optimal diagnostic performance is uncertain.
Methods
We performed a systematic review and harmonised individual patient-level data to evaluate the diagnostic performance of BNP and MRproANP for the diagnosis of acute heart failure using random-effects meta-analysis. We subsequently developed and externally validated a decision-support tool called CoDE-HF for both BNP and MRproANP that combines the natriuretic peptide concentrations with clinical variables using machine learning to report the probability of acute heart failure for an individual patient.
Results
Fourteen studies from 12 countries provided individual patient-level data in 8,493 patients for BNP and 3,847 patients for MRproANP, in whom, 48.3% (4,105/8,493) and 41.3% (1,611/3899) had an adjudicated diagnosis of acute heart failure, respectively. The negative and positive predictive values of guideline-recommended thresholds for BNP (100 pg/mL) and MR-proANP (120 pg/mL) were 93.6% (95% confidence interval 88.4–96.6%) and 68.8% (62.9–74.2%), and 95.6% (92.2–97.6%) and 64.8% (56.3–72.5%), respectively. However, we observed significant heterogeneity in the diagnostic performance across important patient subgroups (Figure 1). In the external validation cohort, CoDE-HF was well calibrated with excellent discrimination in those without prior acute heart failure for both BNP and MRproANP (area under the curve of 0.946 [0.933–0.958] and 0.943 [0.921–0.964], and Brier scores of 0.105 and 0.073, respectively). CoDE-HF performed consistently across all subgroups for both BNP and MRproANP, and identified 30% and 65.7% at low-probability (negative predictive value of 99.1% [98.8–99.3%] and 99.1% [98.8–99.4%]), and 30% and 17.3% at high-probability (positive predictive value of 91.3% [90.7–91.9%] and 70.0% [68.5–71.4%]) in those without prior heart failure, respectively (Figure 2).
Conclusion
In an international collaborative analysis, we observed that guideline-recommended thresholds for BNP and MRproANP to diagnose acute heart failure varied significantly across patient subgroups. A decision-support tool using machine learning to combine natriuretic peptides as a continuous measure and other clinical variables provides a more accurate and individualised approach.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Medical Research Council and British Heart Foundation Figure 1. NPV of BNP threshold (100 pg/mL)Figure 2. NPV of the CoDE-HF rule-out score
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Affiliation(s)
- D Doudesis
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - K K Lee
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - M Anwar
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - F Astengo
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - D Newby
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - A Japp
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - A Tsanas
- University of Edinburgh, Usher Institute, Edinburgh, United Kingdom
| | - A Shah
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - M Richards
- University of Otago, Christchurch Heart Institute, Christchurch, New Zealand
| | - J McMurray
- University of Glasgow, BHF Cardiovascular Research Centre, Glasgow, United Kingdom
| | - C Mueller
- University Hospital Basel, Cardiovascular Research Institute of Basel, Basel, Switzerland
| | - J Januzzi
- Massachusetts General Hospital, Division of Cardiology, Boston, Massachusetts, United States of America
| | - N Mills
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
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Bularga A, Wereski R, Taggart C, Lowry M, Singh T, Lee KK, Anand A, Shah ASV, Ross DA, Perry MR, Dweck MR, Newby DE, Chapman AR, Mills NL. Mechanisms of myocardial injury and clinical outcomes in patients hospitalised with suspected COVID-19. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1154] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Myocardial injury is associated with adverse outcomes in patients with COVID-19. However, the prognostic role of myocardial injury in COVID-19 compared to other acute illnesses and the underlying mechanisms of injury are poorly understood.
Methods
In a prospective, multi-centre, cohort study conducted in secondary and tertiary care hospitals in Scotland, all consecutive patients with suspected COVID-19 underwent cardiac troponin (ARCHITECTSTAT high-sensitive troponin I (hs-cTnI) assay; Abbott Laboratories) testing in plasma that was surplus to clinical requirements. The results were not reported unless required by the attending clinician. We evaluated the prevalence of myocardial injury, mechanisms and outcomes in all patients. In those with any hs-cTnI concentration above the sex-specific 99th centile the diagnosis was adjudicated according to the 4th Universal Definition of Myocardial Infarction. The primary outcome of all-cause mortality was compared in those with and without myocardial injury and COVID-19 by cox regression adjusted for age, sex, renal function and co-morbidities.
Results
A total of 2,916 (median age 69 [interquartile range, IQR 54–79] years, 53% women) consecutive patients with suspected COVID-19 were followed up for 228 [IQR 203–249] days. Myocardial injury occurred in 26% (750/2,916) with a median troponin concentration of 66 [35–178] ng/L; the prevalence was 41% (46/112) and 25% (704/2,804) in those with and without COVID-19, respectively. The most common mechanism was acute non-ischaemic myocardial injury occurring in 80% (37/46) and 71% (502/704) of patients with and without COVID-19, respectively. Type 1 myocardial infarction (2% and 4%), type 2 myocardial infarction (7% and 14%) and chronic myocardial injury (11% and 11%) were less common and only one patient had confirmed myocarditis. In patients with myocardial injury mortality was increased compared to those without (P<0.001 log rank), whether they had COVID-19 (54% [25/46] versus 26% [17/66]) or not (35% [248/704] versus 14% [294/2100]). Myocardial injury was an independent predictor of death in all patients (adjusted hazard ratio [aHR] 2.04, 95% confidence interval [CI] 1.71 to 2.43), but this excess risk was not higher in patients with COVID-19 (aHR 1.58, 95% CI 0.75 to 3.15) compared to those without the condition (aHR 2.01, 95% CI 1.81 to 2.49).
Conclusion
Myocardial injury is common in hospitalised patients with suspected COVID-19 whether or not COVID-19 was the cause of their presentation. The majority of patients had acute non-ischaemic myocardial injury rather than a defined cardiac condition. Despite this the presence of myocardial injury was an independent predictor of death in all hospitalised patients.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation Kaplan-Meier curve for all-cause death
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Affiliation(s)
- A Bularga
- University of Edinburgh, Edinburgh, United Kingdom
| | - R Wereski
- University of Edinburgh, Edinburgh, United Kingdom
| | - C Taggart
- University of Edinburgh, Edinburgh, United Kingdom
| | - M Lowry
- University of Edinburgh, Edinburgh, United Kingdom
| | - T Singh
- University of Edinburgh, Edinburgh, United Kingdom
| | - K K Lee
- University of Edinburgh, Edinburgh, United Kingdom
| | - A Anand
- University of Edinburgh, Edinburgh, United Kingdom
| | - A S V Shah
- London School of Hygiene and Tropical Medicine, Department of Cardiology, London, United Kingdom
| | - D A Ross
- Western General Hospital, Regional Infectious Disease Unit, Edinburgh, United Kingdom
| | - M R Perry
- Western General Hospital, Regional Infectious Disease Unit, Edinburgh, United Kingdom
| | - M R Dweck
- University of Edinburgh, Edinburgh, United Kingdom
| | - D E Newby
- University of Edinburgh, Edinburgh, United Kingdom
| | - A R Chapman
- University of Edinburgh, Edinburgh, United Kingdom
| | - N L Mills
- University of Edinburgh, Edinburgh, United Kingdom
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Bularga A, Anand A, Strachan FE, Lee KK, Stewart S, Ferry AV, Chapman AR, Marshall L, Shah ASV, Newby DE, Mills NL. 247Safety and efficacy of high-sensitivity cardiac troponin for risk stratification in patients with suspected acute coronary syndrome. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0064] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Guidelines acknowledge the emerging role of high-sensitivity cardiac troponin (hs-cTn) assays for the risk stratification and rapid rule-out of myocardial infarction, but multiple approaches have been described. We previously demonstrated the utility of a single hs-cTnI concentration <5 ng/L at presentation to risk stratify patients with suspected acute coronary syndrome (ACS).
Purpose
To assess the safety and efficacy of a hs-cTnI concentration <5 ng/L at presentation in consecutive patients included in the High-STEACS (High-SensitivityTroponin in the Evaluation of patients with Acute Coronary Syndrome) randomised controlled trial.
Methods
The High-STEACS trial was a stepped wedge cluster randomised controlled trial in ten hospitals across Scotland that included 48,282 patients in whom high-sensitivity cardiac troponin was requested by the attending clinician for evaluation of suspected ACS. Patients with ST-segment elevation myocardial infarction (STEMI) were excluded. We evaluated the negative predictive value (NPV) and sensitivity of a presentation hs-cTnI <5 ng/L for a composite outcome of type 1 myocardial infarction, or subsequent type 1 myocardial infarction or cardiac death at 30 days. To assess safety, we report the one-year risk of type 1 myocardial infarction or cardiac death. To assess efficacy, we report the proportion of patients with cardiac troponin <5 ng/L at presentation.
Results
We included 47,101 consecutive patients in the analysis (mean 61±17 years old, 47% female). Of these patients, 27,500 (58%) had a cardiac troponin <5 ng/L at presentation. Overall, 4,313/47,101 (9%) patients had a composite outcome at 30 days, but the event rate was only 0.4% in those with troponin <5 ng/L (98/27,500). The NPV for the composite outcome in those <5 ng/L was 99.7% (95% confidence intervals [CI] 99.6–99.7) and the sensitivity was 98.0% (95% CI 97.6–98.4). In those without evidence of myocardial injury at presentation (hs-cTnI <99thcentile), type 1 myocardial infarction or cardiac death at one year occurred in 197 (0.7%) patients with cardiac troponin <5 ng/L, compared to 647 (5.5%) of those ≥5 ng/L. The NPV was unchanged across all age groups, although efficacy fell as fewer older patients had hs-cTnI concentrations below the risk stratification threshold (see Figure).
Conclusion
A hs-cTnI concentration <5 ng/L at presentation identifies the majority of patients with suspected ACS as low-risk of early or late cardiac events. Although the proportion identified as low risk is reduced in older populations, the safety of this risk stratification approach is maintained across patients of all ages.
Acknowledgement/Funding
British Heart Foundation
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Affiliation(s)
- A Bularga
- University of Edinburgh, Edinburgh, United Kingdom
| | - A Anand
- University of Edinburgh, Edinburgh, United Kingdom
| | - F E Strachan
- University of Edinburgh, Edinburgh, United Kingdom
| | - K K Lee
- University of Edinburgh, Edinburgh, United Kingdom
| | - S Stewart
- University of Edinburgh, Edinburgh, United Kingdom
| | - A V Ferry
- University of Edinburgh, Edinburgh, United Kingdom
| | - A R Chapman
- University of Edinburgh, Edinburgh, United Kingdom
| | - L Marshall
- University of Edinburgh, Edinburgh, United Kingdom
| | - A S V Shah
- University of Edinburgh, Edinburgh, United Kingdom
| | - D E Newby
- University of Edinburgh, Edinburgh, United Kingdom
| | - N L Mills
- University of Edinburgh, Edinburgh, United Kingdom
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7
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Shah A, McAllister D, Astengo F, Perez J, Lee KK, Gallacher P, Hall J, Bing R, Anand A, Newby D, Mills N, Cruden N. 3325Incidence, outcomes and microbiology in patients with infective endocarditis. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0077] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Despite recent improvements in management, infective endocarditis remains associated with high morbidity and mortality. Over the last few decades, several factors have impacted on both the incidence and outcomes following infective endocarditis.
Purpose
Using a national linkage approach, we describe the changing age- and sex-stratified incidence and outcomes of infective endocarditis in Scotland over the last 25 years.
Methods
We conducted a consecutive retrospective individual patient linkage study across multiple national databases. Using data extracted from the Scottish hospital discharge dataset held by the Information Services Division of NHS National Services Scotland, we extracted episodes for all patients aged 20 years or older who were admitted with infective endocarditis between January 1, 1990, and December 31, 2014 in Scotland, UK. Patient episodes with infective endocarditis were linked to national prescribing and microbiology databases. The primary outcome was 1-year mortality following the index presentation. Generalised additive models were constructed to estimate the crude and age- and sex-stratified incidence rates (using a poison distribution) as well as trends in mortality (using a binomial distribution) adjusted for age, sex and comorbidity.
Results
Across 12,446 individual patients, there were a total of 12,667 hospitalisations (mean age 68±17 years, 55% females) with infective endocarditis using a 5-year look back period. The estimated crude rate of hospitalisation increased from 7.38 per 100,000 (95% CI 6.58 to 8.28) in 1990 to 15.09 per 100,000 (95% CI 13.90 to 16.39) in 2014 (p<0.001). Over the period of the study, 31% (3,877/12,667) of people admitted to hospital with infective endocarditis died within one year of admission. Case fatality fell markedly in both men and women from 1990 to 2014 (Figure). Microbiology was status was available for 34% of all hospitalisations with staphylococcus cultures associated with worse outcomes.
Conclusions
Despite the crude incidence of infective endocarditis doubling over the last 25 years and case fatality remaining high, the risk of death has markedly fallen over the last two decades. Staphylococcus cultures remain an independent marker of poor prognosis in this cohort.
Acknowledgement/Funding
British Heart Foundation
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Affiliation(s)
- A Shah
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | | | - F Astengo
- University of Edinburgh, Edinburgh, United Kingdom
| | - J Perez
- University of Glasgow, Glasgow, United Kingdom
| | - K K Lee
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - P Gallacher
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - J Hall
- University of Edinburgh, Edinburgh, United Kingdom
| | - R Bing
- University of Edinburgh, Edinburgh, United Kingdom
| | - A Anand
- University of Edinburgh, Edinburgh, United Kingdom
| | - D Newby
- University of Edinburgh, Edinburgh, United Kingdom
| | - N Mills
- University of Edinburgh, Edinburgh, United Kingdom
| | - N Cruden
- University of Edinburgh, Edinburgh, United Kingdom
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8
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Gallacher PJ, Miller-Hodges E, Shah A, Anand A, Lee KK, Chapman AR, Farrah T, Halbesma N, Blackmur J, Newby DE, Mills NL, Dhaun N. P1578Outcomes in patients with renal impairment and myocardial injury or infarction identified by high-sensitivity cardiac troponin testing: a secondary analysis of the High-STEACS trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0338] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Patients with renal impairment are at increased risk of myocardial infarction (MI), but the interpretation of cardiac troponin is challenging in this setting. The use of high-sensitivity cardiac troponin (hs-cTn) assays increases the detection of myocardial injury, yet may contribute to uncertainty in the diagnosis of MI in those with renal impairment.
Purpose
To describe the diagnosis and outcomes of patients with myocardial injury or infarction identified using a hs-cTnI assay, stratified by renal function.
Methods
In a pre-specified secondary analysis of a stepped-wedge cluster-randomised controlled trial, we identified consecutive patients with a hs-cTnI concentration greater than the sex-specific 99th centile between June 2013 and March 2016. The diagnoses of type 1 or type 2 MI were adjudicated and classified according to the 4th Universal Definition of Myocardial Infarction. Renal impairment was defined as an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73m2.The primary outcome of type 1 or type 4b MI or cardiovascular death was compared in patients with and without renal impairment at 1 year.
Results
A measure of renal function was available in 47,334 (98.0%) patients, of whom 7,933 (16.8%) had renal impairment (mean age 76±12 years; 54% female). Plasma hs-cTnI concentrations were >99th centile in 47.9% (3,800/7,933) of patients with renal impairment and 16.3% (6,439/39,401) of patients with normal renal function. In those with and without renal impairment, the adjudicated diagnosis was type 1 MI in 35.2% (1,336/3,800) and 55.8% (3,596/6,439) of patients, and type 2 MI in 12.6% (480/3,800) and 9.7% (626/6,439) of patients, respectively (P<0.001 for both). In patients with hs-cTnI concentrations >99th centile, the primary outcome occurred in 24.9% (945/3,800) of patients with renal impairment, compared to 12.1% (779/6,439) of patients with normal renal function (P<0.001). In patients with type 1 MI, the primary outcome occurred in 32.6% (436/1,336) of those with renal impairment and 11.7% (419/3,596) of those without (P<0.001). In patients with type 2 MI, the primary outcome occurred in 20.4% (98/480) and 9.9% (62/626) of patients with and without renal impairment, respectively (P<0.001).
Conclusion
Almost half of all patients with suspected acute coronary syndrome and renal impairment have hs-cTnI concentrations greater than the sex-specific 99th centile. Whilst only one in three had a diagnosis of type 1 MI, an elevated troponin concentration was associated with a poorer prognosis in those with concomitant renal impairment compared to those without, irrespective of the index diagnosis.
Acknowledgement/Funding
British Heart Foundation
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Affiliation(s)
- P J Gallacher
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - E Miller-Hodges
- Royal Infirmary of Edinburgh, Department of Renal Medicine, Edinburgh, United Kingdom
| | - A Shah
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A Anand
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - K K Lee
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A R Chapman
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - T Farrah
- Royal Infirmary of Edinburgh, Department of Renal Medicine, Edinburgh, United Kingdom
| | - N Halbesma
- University of Edinburgh, Edinburgh, United Kingdom
| | - J Blackmur
- University of Edinburgh, Edinburgh, United Kingdom
| | - D E Newby
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - N L Mills
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - N Dhaun
- Royal Infirmary of Edinburgh, Department of Renal Medicine, Edinburgh, United Kingdom
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9
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Lee KK, Ferry AV, Anand A, Strachan FE, Chapman AR, Newby DB, Tuck C, Keerie C, Weir CJ, Shah ASV, Mills NL. P1731High-sensitivity troponin with sex-specific thresholds in suspected acute coronary syndrome. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0486] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Introduction
Major disparities between women and men in the diagnosis, management and outcome of acute coronary syndrome are well recognised. Whether sex-specific diagnostic thresholds for myocardial infarction will address these differences is uncertain.
Purpose
To evaluate the impact of implementing a high-sensitivity cardiac troponin I (hs-cTnI) assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome.
Methods
In a stepped-wedge, cluster-randomized controlled trial across ten hospitals we evaluated the implementation of a hs-cTnI assay in 48,282 (47% women) consecutive patients with suspected acute coronary syndrome. During a validation phase the hs-cTnI assay results were suppressed and a contemporary cTnI assay with a single threshold was used to guide care. Myocardial injury was defined as any hs-cTnI concentration >99th centile of 16 ng/L in women and 34 ng/L in men. The primary outcome was myocardial infarction after the initial presentation or cardiovascular death at 1 year. In this prespecified analysis, we evaluated outcomes in men and women before and after implementation of the hs-cTnI assay.
Results
Use of the hs-cTnI assay with sex-specific thresholds increased myocardial injury in women by 42% (from 3,521 (16%) to 4,991 (22%)) and by 6% in men (from 5,068 (20%) to 5,369 (21%)). Whilst treatment increased in both sexes, women with myocardial injury remained less likely than men to undergo coronary revascularisation (15% versus34%), or to receive dual anti-platelet (26% versus43%), statin (16% versus26%) or other preventative therapies (P<0.001 for all). The primary outcome occurred in 18% (369/2,072) and 17% (488/2,919) of women with myocardial injury during the validation and implementation phase respectively (adjusted hazard ratio 1.11, 95% confidence interval 0.92 to 1.33), compared to 18% (370/2,044) and 15% (513/3,325) of men (adjusted hazard ratio 0.85, 95% confidence interval 0.71 to 1.01).
Patient management
Conclusion
Use of sex-specific thresholds identified five-times more additional women than men with myocardial injury, such that the proportion of women and men with myocardial injury is now similar. Despite this increase, women received approximately half the number of treatments for coronary artery disease as men and their outcomes were not improved.
Acknowledgement/Funding
The British Heart Foundation
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Affiliation(s)
- K K Lee
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A V Ferry
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A Anand
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - F E Strachan
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A R Chapman
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - D B Newby
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - C Tuck
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - C Keerie
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - C J Weir
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A S V Shah
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - N L Mills
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
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10
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Anand A, Shah ASV, Strachan FE, Lee KK, Chapman AR, Bularga A, Stewart S, Ferry A, Marshall L, Newby DE, Mills NL. P3593Improving the performance of high-sensitivity cardiac troponin for the diagnosis of myocardial infarction. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0453] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Universal Definition of Myocardial Infarction (UDMI) mandates a rise and/or fall in high-sensitivity cardiac troponin (hs-cTn) concentration with at least one measure above the 99th centile of a healthy reference population. However, the 99th centile varies by age, sex, and prevalence of comorbid disease within reference populations, and the application of a single threshold may create diagnostic uncertainty in unselected patients attending the Emergency Department.
Purpose
To compare performance of hs-cTnI at the 99th centile with a model that includes additional clinical variables, for the diagnosis of type 1 myocardial infarction.
Methods
The High-Sensitivity Troponin in the Evaluation of patients with Acute Coronary Syndrome (High-STEACS trial) was a stepped wedge cluster randomised controlled trial of 48,282 consecutive patients across 10 hospitals in Scotland. We evaluated the positive predictive value (PPV) of a hs-cTnI >99th centile for a diagnosis of type 1 myocardial infarction. Patients with ST-segment elevation myocardial infarction (STEMI) were excluded, and all were adjudicated according to the 4th UDMI. The study population was randomly divided into derivation (80%) and internal validation (20%) cohorts. Using generalised additive modelling, we tested the effect of adding clinically relevant variables to hs-cTnI for the prediction of type 1 myocardial infarction in the derivation cohort, and assessed performance of the final model in the validation cohort.
Results
We included 47,101 consecutive patients (61±17 years, 47% female), of whom 9,057 (19%) had at least one hs-cTnI >99th centile (7,207 in derivation and 1,850 in validation cohorts). There were 4,087 (45%) patients with type 1 myocardial infarction, with 3239 (45%) and 848 (46%) in the derivation and validation cohorts, respectively. Across the study population, PPV for type 1 myocardial infarction reduced markedly with increasing age (Figure). Age, sex, chest pain, ischaemia on the electrocardiogram, creatinine and rate of change of hs-cTnI were included in the model. Comorbidities (ischaemic heart disease, diabetes, stroke and hyperlipidaemia) did not improve model performance. In the validation cohort, the area under the curve (AUC) for type 1 myocardial infarction using the 99th centile alone was 0.72 (95% CI 0.70–0.74), whereas the AUC for the optimised model was 0.84 (95% CI 0.82–0.85) (p<0.001 by DeLong's test for difference, see Figure).
Figure 1
Conclusion
The diagnostic performance of the 99th centile for type 1 myocardial infarction is poor, particularly in older populations. A simple model including readily available clinical features improves diagnostic performance and with further external validation could support more individualised treatment decisions.
Acknowledgement/Funding
British Heart Foundation
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Affiliation(s)
- A Anand
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A S V Shah
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - F E Strachan
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - K K Lee
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A R Chapman
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A Bularga
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - S Stewart
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A Ferry
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - L Marshall
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - D E Newby
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - N L Mills
- University of Edinburgh, Centre for Cardiovascular Science, Edinburgh, United Kingdom
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11
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Chapman AR, Adamson PD, Anand A, Shah ASV, Lee KK, Strachan FE, Ferry ASV, Sandeman DE, Berry C, Gray AJ, Tuck C, Fox KAA, Newby DE, Weir C, Mills NL. 249High-sensitivity cardiac troponin and the universal definition of myocardial infarction: a randomised controlled trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0066] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The Universal Definition of Myocardial Infarction recommends the 99th centile diagnostic threshold using a high-sensitivity cardiac troponin (hs-cTn) assay and the classification of patients by the etiology of myocardial injury. Whether implementation of this definition improves risk stratification, treatment or outcomes is unknown.
Methods
In a stepped-wedge cluster randomized controlled trial, we implemented a high-sensitivity troponin assay and the recommendations of the Universal Definition in 48,282 consecutive patients with suspected acute coronary syndrome across ten hospitals. In a pre-specified secondary analysis, we compared the primary outcome of myocardial infarction or cardiovascular death, and secondary outcome of non-cardiovascular death at one year across diagnostic categories as per the Fourth Universal Definition. We applied competing risks methodology in all analyses, using a cumulative incidence function and determining the cause-specific hazard ratio (csHR) for competing outcomes.
Results
Cardiac troponin concentrations were elevated in 21.5% (10,360/48,282) of all trial participants. Implementation increased the diagnosis of type 1 myocardial infarction by 11% (510/4,471), type 2 myocardial infarction by 22% (205/916), acute myocardial injury by 36% (443/1,233) and chronic myocardial injury by 43% (389/898). The risk and rate of the primary outcome was highest in those with type 1 myocardial infarction, whereas the risk and rate of non-cardiovascular death was highest in those with acute myocardial injury (Table, Figure). Despite increases in anti-platelet therapy and coronary revascularization after implementation, the primary outcome was unchanged in patients with type 1 myocardial infarction (csHR 1.00, 95% CI 0.82 to 1.21), or in any other category.
Adjusted csHR for competing outcomes Myocardial infarction or cardiovascular death Non-cardiovascular death Adjusted csHR (95% CI) Adjusted csHR (95% CI) Type 1 myocardial infarction 5.64 (5.12 to 6.22) 0.83 (0.72 to 0.96) Type 2 myocardial infarction 3.50 (2.94 to 4.15) 1.72 (1.44 to 2.06) Acute myocardial injury 4.38 (3.80 to 5.05) 2.65 (2.33 to 3.00) Chronic myocardial injury 3.88 (3.31 to 4.55) 2.06 (1.77 to 2.40) Cox regression models adjusted for age, sex, diabetes, ischaemic heart disease, season, days since trial onset and site of recruitment (as a random effect).
Cumulative incidence and number at risk
Conclusions
Implementation of the recommendations of the Universal Definition identified patients with different risks of future cardiovascular and non-cardiovascular events, but did not improve outcomes. Greater understanding of the underlying mechanisms and effective strategies for the investigation and treatment of patients with myocardial injury and infarction are required if we are to improve outcomes.
Acknowledgement/Funding
British Heart Foundation
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Affiliation(s)
- A R Chapman
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - P D Adamson
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A Anand
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A S V Shah
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - K K Lee
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - F E Strachan
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A S V Ferry
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - D E Sandeman
- Victoria Hospital, Cardiology, Kirkcaldy, United Kingdom
| | - C Berry
- Cardiovascular Research Centre of Glasgow, Glasgow, United Kingdom
| | - A J Gray
- Royal Infirmary of Edinburgh, Department of Emergency Medicine, Edinburgh, United Kingdom
| | - C Tuck
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - K A A Fox
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - D E Newby
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - C Weir
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - N L Mills
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
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Tan K, Chow WS, Leung J, Ho A, Ozaki R, Kam G, Li J, Choi CH, Tsang MW, Chan N, Lee KK, Chan KW. Clinical considerations when adding a sodium-glucose co-transporter-2 inhibitor to insulin therapy in patients with diabetes mellitus. Hong Kong Med J 2019; 25:312-319. [PMID: 31416990 DOI: 10.12809/hkmj197802] [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] [Indexed: 11/05/2022] Open
Affiliation(s)
- K Tan
- Department of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - W S Chow
- Department of Medicine, Queen Mary Hospital, Pokfulam, Hong Kong
| | - J Leung
- Department of Integrated Medical Service, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong
| | - A Ho
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | - R Ozaki
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - G Kam
- Department of Medicine and Geriatrics, United Christian Hospital, Kwun Tong, Hong Kong
| | - J Li
- Department of Medicine, Yan Chai Hospital, Tsuen Wan, Hong Kong
| | - C H Choi
- Department of Medicine, Queen Elizabeth Hospital, Jordan, Hong Kong
| | - M W Tsang
- Specialist in Endocrinology, Private Practice
| | - N Chan
- Specialist in Endocrinology, Private Practice
| | - K K Lee
- Department of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - K W Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Laichikok, Hong Kong
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Burford C, Cheng A, Jayne M, Alexander EC, Hall J, Lee KK, Patel AS. 42THE IMPACT OF DEMENTIA ON MORTALITY IN ACUTE MEDICAL ADMISSIONS. Age Ageing 2018. [DOI: 10.1093/ageing/afy121.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- C Burford
- Faculty of Life Sciences and Medicine, King’s College London
| | - A Cheng
- Faculty of Life Sciences and Medicine, King’s College London
| | - M Jayne
- Faculty of Life Sciences and Medicine, King’s College London
| | - E C Alexander
- Faculty of Life Sciences and Medicine, King’s College London
| | - J Hall
- King’s College Hospital, London, UK
| | - K K Lee
- King’s College Hospital, London, UK
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14
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Cheng A, Alexander EC, Burford C, Jayne M, Hall J, Patel AS, Lee KK. 40THE RELATIONSHIP BETWEEN LIVING ARRANGEMENT, CARE PACKAGES AND INPATIENT DEATHS IN OLDER ADULTS: A RETROSPECTIVE STUDY AT A LONDON TEACHING HOSPITAL. Age Ageing 2018. [DOI: 10.1093/ageing/afy121.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- A Cheng
- Faculty of Life Sciences and Medicine, King’s College London
| | - E C Alexander
- Faculty of Life Sciences and Medicine, King’s College London
| | - C Burford
- Faculty of Life Sciences and Medicine, King’s College London
| | - M Jayne
- Faculty of Life Sciences and Medicine, King’s College London
| | - J Hall
- King’s College Hospital, London, UK
| | | | - K K Lee
- King’s College Hospital, London, UK
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15
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Chapman AR, Hesse K, Andrews JPM, Lee KK, Anand A, Ferry A, Stewart S, Marshall L, Strachan FE, Shah AS, Newby DE, Mills NL. 1085High-sensitivity cardiac troponin I and clinical risk scores in patients with suspected acute coronary syndrome. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.1085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A R Chapman
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - K Hesse
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - J P M Andrews
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - K K Lee
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A Anand
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A Ferry
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - S Stewart
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - L Marshall
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - F E Strachan
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - A S Shah
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - D E Newby
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - N L Mills
- University of Edinburgh, BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
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16
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Cho PSP, Rainey A, Mukherjee B, Lee KK. P70 CPAP compliance in bariatric patients with obstructive sleep apnoea. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.213] [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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Kim YG, Kim SY, Kim JH, Lee KK, Yun YM. Prevalence and Clinical Relevance of Exon 2 Deletion of COMMD1 in Bedlington Terriers in Korea. J Vet Intern Med 2016; 30:1846-1850. [PMID: 27727471 PMCID: PMC5115198 DOI: 10.1111/jvim.14590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 01/17/2016] [Revised: 07/28/2016] [Accepted: 08/31/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Deletion of exon 2 of copper metabolism domain containing 1 (COMMD1) results in copper toxicosis in Bedlington terriers (CT-BT). OBJECTIVES This study was conducted to identify the prevalence and clinical relevance of the COMMD1 mutation in Bedlington terriers in Korea. ANIMALS A total of 105 purebred Bedlington terriers (50 males, 55 females) from the kennels and pet dog clubs in Korea were examined during the period 2008-2013. METHODS A multiplex PCR was carried out to detect exon 2 deletion of COMMD1. Clinical analysis was performed on each genetic group, and clinical status of the dogs was followed up to estimate survival probability. RESULTS Of the 105 samples, 52 (49%) were wild-type homozygote, 47 (45%) were heterozygote, and 6 (6%) were mutant-type homozygote. Plasma alanine aminotransferase (ALT) activity was increased in the mutant-type homozygous group >2 years of age (P < .0001). The survival probability of 6 mutant-type homozygotes surviving 2.5 years was 0.67, and 4 years was 0.5. CONCLUSIONS AND CLINICAL IMPORTANCE Results show the prevalence and clinical relevance of exon 2 deletion of COMMD1 and could help establish a structured selective breeding program to prevent CT-BT in Korea.
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Affiliation(s)
- Y G Kim
- Department of Internal Medicine, College of Veterinary Medicine, Jeju National University, Jeju, Korea
| | - S Y Kim
- Department of Internal Medicine, College of Veterinary Medicine, Jeju National University, Jeju, Korea
| | - J H Kim
- Department of Internal Medicine, College of Veterinary Medicine, Jeju National University, Jeju, Korea.,Veterinary Medical Research Institute, Jeju National University, Jeju, Korea
| | - K K Lee
- Department of Internal Medicine, College of Veterinary Medicine, Jeju National University, Jeju, Korea.,Veterinary Medical Research Institute, Jeju National University, Jeju, Korea
| | - Y M Yun
- Department of Internal Medicine, College of Veterinary Medicine, Jeju National University, Jeju, Korea.,Veterinary Medical Research Institute, Jeju National University, Jeju, Korea
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Cheung E, Bow C, Loong C, Lee KK, Ho AYY, Soong C, Chan YY, Tan KCB, Kung AWC. A secular increase in BMD in Chinese women. J Bone Miner Metab 2014; 32:48-55. [PMID: 23636506 DOI: 10.1007/s00774-013-0463-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 03/19/2013] [Indexed: 02/04/2023]
Abstract
Population-based studies have revealed a decline in the incidence of age-adjusted hip fractures in southern Chinese women during the past decade. To determine whether there was a secular change in population characteristics that accounted for this decline, we compared the bone mineral density (BMD) and lifestyle habits of two cohorts of women who were more than 50 years of age and who were recruited from 1995 to 2000 and 2005 to 2010. The BMD levels in the 2005-2010 cohort were significantly higher at the spine and hip and ranged from 3.6 to 17.8% among the different age groups. Additionally, a significantly lower prevalence of subjects with osteoporosis and osteopenia was observed. Longer reproductive years, higher levels of physical activity, higher estradiol and 25(OH) vitamin D levels, and lower alkaline phosphatase levels were found in the 2005-2010 cohort. After adjusting for bone-determining factors, significant differences were detected in the BMD levels at the lumbar spine, femoral neck, and total hip (4.17, 9.02, and 9.34%, respectively) in women >50 years of age but not in women ≤50 years of age. The secular increase in BMD and healthier lifestyles most likely led to the decline in the incidence of age-adjusted fractures.
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Affiliation(s)
- Elaine Cheung
- Department of Medicine, The University of Hong Kong and Queen Mary Hospital, Hospital Authority, Hong Kong, China
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Ruickbie SV, Kursumovic E, Narayan B, Opong K, Luce P, Toma T, Baker LV, Lee KK. P13 Mismatch Between Clinical and Radiological Diagnosis of Pneumonia: Abstract P13 Table 1. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.154] [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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20
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Lee KK, Ward K, Raywood E, Moxham J, Rafferty GF, Birring SS. P161 Cough Intensity in Voluntary, Induced and Spontaneous Cough: Abstract P161 Table 1. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.222] [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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21
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Lee KK, Ward K, Raywood E, Moxham J, Rafferty GF, Birring SS. P160 Increased cough intensity in patients with chronic cough: Abstract P160 Table 1. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.221] [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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23
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Lee KK, Matos S, Ward K, Raywood E, Evans DH, Moxham J, Rafferty GF, Birring SS. P158 Cough Sound Intensity: The Development of a Novel Measure of Cough Severity: Abstract P158 Table 1. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
We have previously screened 150 medicinal plants for the inhibition of elastase and found significant inhibitory effects of the extracts of Areca catechu L. on the ageing and inflammation of skin tissues. To isolate and identify the compounds having biological activity, they were further purified by each fraction of solvents, silica gel column chromatography, preparative TLC and reversed-phase HPLC. The peak in HPLC, which coincided with the inhibitory activity against elastase, was identified as a phenolic substance by using various colorimetric methods, UV and IR. IC(50) values of this phenolic substance were 26.9 mug mL(-1) for porcine pancreatic elastase (PPE) and 60.8 mug mL(-1) for human neutrophil elastase (HNE). This phenolic substance showed more potent activity than that of reference compounds, oleanolic acid (76.5 mug mL(-1) for PPE, 219.2 mug mL(-1) for HNE) and ursolic acid (31.0 mug mL(-1) for PPE, 118.6 mug mL(-1) for HNE). According to the Lineweaver-Burk plots, the inhibition against both PPE and HNE by this phenolic substance was competitive inhibition with the substrate. The phenolic substance from A. catechu effectively inhibited hyaluronidase activity (IC(50) : 210 mug mL(-1) ). These results suggest that the phenolic substance purified from A. catechu has an anti-ageing effect by protecting connective tissue proteins.
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Affiliation(s)
- K K Lee
- R & D Center, Coreana Cosmetic Co. Ltd, Jeongchon-ri, Seonggeo-Eup, Cheonan-Si, Chungnam, 330-830, Korea
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Lee KK, Mills NL, McAllister DA, Churchhouse AMD, MacLeod M, Stoddart M, Walker S, Denvir MA, Fox KAA, Newby DE. 128 Implications of lowering the threshold of cardiac troponin in the diagnosis of myocardial infarction. Heart 2012. [DOI: 10.1136/heartjnl-2012-301877b.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Lee KK, Deng S, Fan HM, Mhaisalkar S, Tan HR, Tok ES, Loh KP, Chin WS, Sow CH. α-Fe2O3 nanotubes-reduced graphene oxide composites as synergistic electrochemical capacitor materials. Nanoscale 2012; 4:2958-61. [PMID: 22441701 DOI: 10.1039/c2nr11902a] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
We present a facile approach for the fabrication of a nanocomposite comprising α-Fe(2)O(3) nanotubes (NTs) anchored on reduced graphene oxide (rGO) for electrochemical capacitors (ECs). The hollow tubular structure of the α-Fe(2)O(3) NTs presents a high surface area for reaction, while the incorporation of rGO provides an efficient two-dimensional conductive pathway to allow fast, reversible redox reaction. As a result, the nanocomposite materials exhibit a specific capacitance which is remarkably higher (~7 times) than α-Fe(2)O(3) NTs alone. In addition, the nanocomposites show excellent cycling life and large negative potential window. These findings suggest that such nanocomposites are a promising candidate as negative electrodes in asymmetrical capacitors with neutral electrolytes.
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Affiliation(s)
- K K Lee
- NUS Nanoscience and Nanotechnology Initiative, Block S13, 2 Science Drive 3, Singapore 117542
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Abstract
Hydrogen/deuterium exchange coupled to mass spectrometry (HDX-MS) has emerged as a technique for studying glycoproteins, which are often refractory to classical methods. Glycan chains are generally assumed to exchange protons very rapidly, making them invisible to this technique. Here, we show that under conditions commonly used for HDX-MS, acetamido groups within glycan chains retain a significant amount of deuterium. Using mono- and polysaccharide standards along with glycopeptides from a panel of glycoproteins, we demonstrate that N-acetyl hexosamines, along with modified Asn side chains, are responsible for this effect. Model compounds for sialic acid also displayed similar exchange kinetics, but terminal sialic acids in the context of an entire glycan chain did not contribute to deuterium retention. Furthermore, the presence of sialic acid appears to enhance the exchange rate of the nearby N-acetyl glucosamines. The ability to detect deuterium exchange at the glycan level opens the possibility of applying HDX-MS to monitor glycan interactions and dynamics.
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Affiliation(s)
- M Guttman
- Department of Medicinal Chemistry, University of Washington, Seattle, Washington 98195, USA.
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Tam LS, Li EK, Shang Q, Tomlinson B, Lee VW, Lee KK, Li M, Kuan WP, Li TK, Tseung L, Yip GWK, Freedman B, Yu CM. Effects of rosuvastatin on subclinical atherosclerosis and arterial stiffness in rheumatoid arthritis: a randomized controlled pilot trial. Scand J Rheumatol 2011; 40:411-21. [DOI: 10.3109/03009742.2011.586649] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Jang A, Lee KK, Bishop PL, Kim IS, Ahn CH. Development of polymer lab-on-a-chip (LOC) for oxidation-reduction potential (ORP) measurement. Water Sci Technol 2011; 63:2309-2315. [PMID: 21977654 DOI: 10.2166/wst.2011.645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Reverse osmosis (RO) desalination has been recognized as a promising method to solve the water shortage problem. Nevertheless, since it is energy intensive and has many problems associated with biofouling/fouling of RO membranes in RO plants, its commercial acceptance is still slow. Especially, as high levels of oxidizing agents negatively affect RO membrane efficiency and life span. So, there is a need to develop sensitive, selective, portable and rapid methods to determine oxidation-reduction potential (ORP) in feed solution. For developing a polymer ORP lab-on-a-chip (LOC), a microchannel patterned on a polymer substrate was successfully filled with 800 nm diameter silica beads using self-assembly bead packing technology. The measured ORPs using the three kinds of redox potential solutions were typically slightly lower than those of the nominal redox potential. But, all of the measurements should be deemed acceptable. The ORP LOC has also a much shorter response time than the conventional potentiometric sensor.
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Affiliation(s)
- A Jang
- Department of Environmental Science and Engineering, Gwangju Institute of Science and Technology (GIST), 261 Cheomdan-gwagiro, Buk-gu, Gwangju 500-712, South Korea.
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Ko GT, Chow CC, Leung G, Au-Yeung TW, Chan WB, Lam CS, Lo M, Lee KK. High rate of increased carotid intima-media thickness and atherosclerotic plaques in Chinese asymptomatic subjects with central obesity. Int J Cardiovasc Imaging 2010; 27:833-41. [PMID: 20978850 DOI: 10.1007/s10554-010-9733-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 10/12/2010] [Indexed: 10/18/2022]
Abstract
Both central obesity and increased carotid intima-media thickness (IMT) are markers of atherosclerosis and associated with cardiovascular diseases (CVD). Information of IMT in Chinese subjects with central obesity is limited. This study was performed to assess the rate of atherosclerosis and abnormal IMT in asymptomatic Chinese subjects with central obesity, and to investigate the association between IMT values and CVD risk factors including hypertension, hyperglycaemia and dyslipidaemia. We studied 122 centrally obese adults who had good past health. IMT measurements on carotid arteries were performed and fasting blood taken for plasma glucose and lipid profiles. Abnormal IMT was defined as > 0.9 mm. Atherosclerosis was defined as the presence of one or more visible plague. Of the 122 subjects, the mean (±SD) age was 59.4 ± 5.8 years (median [range]: 59.0 [45-75] years). The median IMT value was 0.70 mm (range: 0.53-1.19 mm) [men vs. women: 0.74 mm vs. 0.66 mm, P-value: < 0.001]. IMT values and the rate of atherosclerosis increased with age and the number of CVD risk factors (P-value for trend: < 0.05). Using binary logistic regression to predict the presence of atherosclerosis with the presence of abnormal IMT, age, gender, and other CVD risk factors as independent variables, age (OR [95% CI] = 1.13 [1.03, 1.23], P = 0.009) and abnormal IMT (OR [95% CI] = 4.05 [1.09, 15.03], P = 0.037) were independently associated with atherosclerosis. In conclusion, among Hong Kong Chinese asymptomatic subjects with central obesity, there was a high rate of CVD risk factors. We found that 19% of these subjects had carotid atherosclerotic plaques and 10% of them had abnormal IMT (>0.9 mm). Carotid IMT study may serve as an appropriate screening tool to diagnose atherosclerosis in the centrally obese middle-aged population.
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Affiliation(s)
- G T Ko
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Lee KK, Cho HI, Chi HS, Kim DY, Chae SL, Huh HJ. [A case of post-essential thrombocythemia myelofibrosis with severe osteosclerosis]. Korean J Lab Med 2010; 30:122-5. [PMID: 20445328 DOI: 10.3343/kjlm.2010.30.2.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm that involves primarily the megakaryocytic lineage. After many years, a few patients with ET may develop bone marrow (BM) fibrosis and rarely develop osteosclerosis. A 60-yr-old female was admitted due to severe left upper quadrant abdominal discomfort. She had been diagnosed as ET 19 yrs ago. On liver computed tomography severe splenomegaly was shown. Laboratory tests revealed WBC 24.3x10(9)/L, hemoglobin 13.4 g/dL, platelets 432x10(9)/L, lactate dehydrogenase 4,065 IU/L (reference range; 240-480). Blood smear demonstrated leukoerythroblastosis, teardrop cells, and giant and hypogranular platelets. BM study revealed inadequate aspirate due to dry tap. BM biopsy showed clusters of dysplastic megakaryocytes, grade 3 fibrosis, and severe osteosclerosis. Major/minor BCR-ABL1 rearrangement and JAK2 V617F mutation were not detected. Cytogenetic studies revealed normal karyotype. According to the 2008 WHO diagnostic criteria, the patient was diagnosed as having post-essential thrombocythemia myelofibrosis with severe osteosclerosis.
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Affiliation(s)
- Kyo Kwan Lee
- Department of Laboratory Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
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Abstract
The acetylene reduction assay for the measurement of N(2) fixation in a water-saturated paddy soil is limited by the slow diffusion of acetylene and ethylene. In laboratory incubation tests, vigorous shaking after the assay period is needed to release ethylene into the gas within the assay vials. Shaking prior to the incubation is also effective for dissolving acetylene in the water-saturated soil. However, a water-saturated soil depth of less than 10 mm during incubation is recommended. In field assays, some amounts of ethylene remain in the water-saturated soil phase of the acetylene reduction assay chamber, but stirring the water-saturated soil before sampling reduces the amount of ethylene remaining in soil. Evidence of a downward movement of acetylene and an upward movement of ethylene through rice plants was obtained. Because of the rapid transfer of acetylene to rice plant roots, an in situ acetylene reduction assay covering a rice hill is likely to detect nitrogen fixation in the proximity of roots where acetylene is easily accessible. Acetylene introduction to the water-saturated soil phase prior to assay did not greatly increase the acetylene reduction rate. Carbon dioxide enrichment in the assay chamber did not enhance nitrogen fixation in a paddy including rice and algae during a 1-day cycle.
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Affiliation(s)
- K K Lee
- The International Rice Research Institute, Los Baños, Laguna, Philippines
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Lee KK, Salamon N. [18F] fluorodeoxyglucose-positron-emission tomography and MR imaging coregistration for presurgical evaluation of medically refractory epilepsy. AJNR Am J Neuroradiol 2009; 30:1811-6. [PMID: 19628624 DOI: 10.3174/ajnr.a1637] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Epilepsy is a chronic disorder affecting approximately 1% of the population of the world. Approximately one third of patients with epilepsy remain refractory to medical therapy. For these patients, surgery is a curative option. In order for surgery to be considered, precise localization of the structural abnormality is needed. When MR imaging findings are normal, more sensitive techniques such as positron-emission tomography (PET) can help find the abnormality. Combining MR imaging and PET information increases the sensitivity of the presurgical evaluation. In this review, we discuss the clinical applications of coregistration of [(18)F] fluorodeoxyglucose (FDG)-PET with MR imaging for medically refractory epilepsy. Because FDG-PET/MR imaging coregistration has been a routine component of the presurgical evaluation for patients with epilepsy at our institution since 2004, we also included cases from our data base that exemplify the utility of this technology to obtain better postsurgical outcomes.
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Affiliation(s)
- K K Lee
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Lee KK, Ryoo NH, Kim ST, Chae SL, Huh HJ. [Evaluation of the BD phoenix automated microbiology system SMIC/ID-2 panel for antimicrobial susceptibility testing of Streptococcus pneumoniae]. Korean J Lab Med 2009; 29:212-7. [PMID: 19571618 DOI: 10.3343/kjlm.2009.29.3.212] [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: 11/19/2022] Open
Abstract
BACKGROUND With the emergence of antimicrobial resistance among Streptococcus pneumoniae, a more accurate and automated antimicrobial susceptibility testing method is essential. We evaluated the BD Phoenix Automated Microbiology System (Becton Dickinson Diagnostic Systems, USA) SMIC/ID-2 panel for antimicrobial susceptibility testing of S. pneumoniae. METHODS A total of 113 clinical strains of S. pneumoniae (88 penicillin susceptible strains, 8 intermediate strains, and 17 resistant strains by 2008 CLSI criteria) were tested. Minimum inhibitory concentrations (MICs) for penicillin, cefotaxime, clindamycin, erythromycin, levofloxacin, trimethoprim/ sulfamethoxazole, tetracycline, and vancomycin were determined by Etest (AB Biodisk, Sweden) and Phoenix System. The results obtained by Phoenix system were compared to those obtained by Etest. RESULTS The overall essential agreement of MICs (within one dilution of MICs) defined by the Phoenix and Etest was 92.3%. Neither very major errors nor major errors were produced, and minor errors were 6.5%. Minor errors were frequently observed in susceptibility testings for penicillin (22.1%), cefotaxime (12.4%), and trimethoprim/sulfamethoxazole (11.5%). CONCLUSIONS The Phoenix SMIC/ID-2 panel provided a simple and rapid susceptibility testing for S. pneumoniae, and the results were in a good agreement with those of Etest. The Phoenix system appears to be an effective automated system in clinical microbiology laboratories.
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Affiliation(s)
- Kyo Kwan Lee
- Department of Laboratory Medicine, Dongguk University International Hospital, Ilsandong-Gu, Goyang, Korea
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Lee KK, Kim ST, Hong KS, Huh HJ, Chae SL. [Evaluation of the Phoenix automated microbiology system for detecting extended-spectrum beta-lactamase in Escherichia coli, Klebsiella species and Proteus mirabilis]. Korean J Lab Med 2009; 28:185-90. [PMID: 18594169 DOI: 10.3343/kjlm.2008.28.3.185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The aim of this study was to compare the BD Phoenix (Beckton Dickinson Diagnostic Systems, USA) extended-spectrum beta-lactamase (ESBL) test with the Clinical and Laboratory Standards Institute (CLSI) ESBL phenotypic confirmatory test by disk diffusion (CLSI ESBL test) in Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca and Proteus mirabilis. METHODS We tested 224 clinical isolates of E. coli, K. pneumoniae, K. oxytoca and P. mirabilis during May 2006 to March 2007. These isolates were examined by the Phoenix and the CLSI ESBL tests simultaneously. For the isolates showing discordant results between the two tests, boronic acid disk test was performed to differentiate AmpC beta-lactamase and ESBL. RESULTS Among the 224 clinical isolates, 75 and 79 isolates were positive for ESBL by CLSI ESBL test and Phoenix test, respectively. Having detected 4 more isolates as ESBL-producers, Phoenix test showed a 98.2% agreement with a 100% sensitivity and 97.3% specificity compared with CLSI ESBL test. Among the four false positive isolates, three were AmpC-positive but ESBL-negative. CONCLUSIONS The BD Phoenix ESBL test was sensitive and specific, and can be used as a rapid and reliable method to detect ESBL production in E. coli, Klebsiella species, and P. mirabilis.
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Affiliation(s)
- Kyo Kwan Lee
- Department of Laboratory Medicine, Dongguk University International Hospital, Goyang, Korea
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Lee KK, Lee SK, Moon IS, Kim DG, Lee MD. Surgical techniques according to anatomic variations in living donor liver transplantation using the right lobe. Transplant Proc 2008; 40:2517-20. [PMID: 18929785 DOI: 10.1016/j.transproceed.2008.07.079] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES In living donor liver transplantation, the right lobe has many anatomic variations in the vascular tree, which could lead to surgical complications. We need to define surgical technique according to anatomy. METHODS From January 2000 to September 2007, 310 living donor liver transplantations using the right lobe were performed in patients with end-stage liver disease. The vascular trees were evaluated preoperatively with computed tomography and magnetic resonance angiography. We classified anatomic points for safe harvest in the hepatic artery, portal vein, and hepatic vein and described technical points based on anatomic variations. RESULT There were many anatomic variations in the hepatic vasculature. Hepatic artery variations were observed in 16.8% of cases. Double hepatic artery was observed in 14 cases (4.5%). Of these 14 cases, reconstruction as a single artery was performed in 6 and dual reconstruction was performed in 8 cases. Portal vein variation was observed in 45 cases (14.5%): Dual anastomosis to right and left portal vein was performed in type III (n = 20; 6.4%) and type IV (n = 3; 1.0%) variations. There were 70 cases of portal vein thrombosis. In 8 of the 70, a jump or interposition graft with iliac vein was utilized. Of the middle hepatic vein variant, segment V vein only was reconstructed in 188 (60.6%) cases. In 21 (6.8%) cases, segment VIII vein only was reconstructed, and in 43 (13.9%) cases, both segment V and segment VIII veins were reconstructed using the recipient's portal vein, a cryopreserved iliac vein, or a prosthetic graft. The most common variation of right inferior hepatic vein was type II (n = 141; 45.5%), which has 1 right inferior hepatic vein. CONCLUSION Living donor liver transplantation using the right lobe can be performed safely, but there is a potential operative risk because of various anatomic variations. To minimize operative complications, anatomic variations should be kept in mind to ensure a safe and successful operation.
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Affiliation(s)
- K K Lee
- Department of Surgery, Catholic University of Korea, Seoul, Korea
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Chae JI, Ju SK, Lee MK, Park JH, Shim JH, Lee KK, Lee DS. [Cloning of rat TARC cDNA and analysis of tissue-specific mRNA expression]. Mol Biol (Mosk) 2008; 42:639-644. [PMID: 18856064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Thymus and activation-regulated chemokine (TARC) is one that selectively controls the migration of type 2-helper T lymphocytes into inflammatory lesions. TARC is a CC chemokine, and plays an essential role in recruiting CC chemokine receptor 4-positive Th2 cells to allergic lesions. We cloned TARC cDNA from rat thymus using RT-PCR. The rat TARC clone contained a full-length open reading frame encoding 93 amino acids that showed 83% and 66% homology with mouse and human homologs, respectively. The expression of TARC mRNA was mainly in the lymphoid organs, for example, the thymus, spleen, and lymph node. The recombinant TARC was expressed in Escherichia coli and purified in an active form. In addition, the purified rat TARC with S-tagged specifically binds to human CCR4 in CD4.CCR4-transfected HOS cells by Cell-binding assay using flow-cytometry. The TARC cDNA clones obtained in this study will be valuable for future studies on allergic diseases in rats.
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Thorat JD, Wang EC, Lee KK, Seow WT, Ng I. Barbiturate therapy for patients with refractory intracranial hypertension following severe traumatic brain injury: its effects on tissue oxygenation, brain temperature and autoregulation. J Clin Neurosci 2007; 15:143-8. [PMID: 17997313 DOI: 10.1016/j.jocn.2006.08.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 08/22/2006] [Accepted: 08/26/2006] [Indexed: 11/30/2022]
Abstract
The aim of this study was to explore the effects of barbiturate coma on cerebral tissue oxygen tension and cerebrovascular pressure reactivity (PRx), as an index of cerebral autoregulation in severe head injury patients. This was a prospective observational clinical study of 12 patients with severe traumatic brain injury, carried out at a tertiary-level neurosurgical intensive care unit between April 2002 and May 2005. All patients received standard neurosurgical intensive care and monitoring. Probes for intracranial pressure (ICP), brain temperature (BT) and brain tissue oxygenation (PTiO2) were inserted into (noncontused) normal-looking white matter. Cerebrovascular PRx was measured as a moving correlation between ICP and arterial blood pressure. Barbiturate coma was instituted when ICP became refractory (ICP>20 mmHg). All data from the multimodal monitoring were digitally extracted and statistically analysed. The mean ICP decreased with barbiturate coma in eight of the 12 patients (75% of the patients), but only four achieved a value below 20 mmHg. Of eight patients with prebarbiturate PTiO2 levels above 10 mmHg, six had a further improvement in oxygenation. Thus, concordant favourable changes in ICP, PRx and PTiO2 with barbiturate coma were seen in those who survived. Effective response to barbiturates can be detected by improved PTiO2 and autoregulation (PRx) in severe head injury patients.
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Affiliation(s)
- J D Thorat
- Acute Brain Injury Research Laboratory, Department of Neurosurgery, Tan Tock Seng Hospital, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore.
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Huh HJ, Lee KK, Kim ES, Chae SL. Analysis of Positive Results in Mediace Rapid Plasma Reagin and Treponema pallidum Latex Agglutination as the Automated Syphilis Test. Ann Lab Med 2007; 27:324-9. [DOI: 10.3343/kjlm.2007.27.5.324] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Hee Jin Huh
- Department of Laboratory Medicine, College of Medicine, Dongguk University, Gyeonggi Province, Korea
| | - Kyo Kwan Lee
- Department of Laboratory Medicine, College of Medicine, Dongguk University, Gyeonggi Province, Korea
| | - Eu Suk Kim
- Department of Internal Medicine, College of Medicine, Dongguk University, Gyeonggi Province, Korea
| | - Seok-Lae Chae
- Department of Laboratory Medicine, College of Medicine, Dongguk University, Gyeonggi Province, Korea
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Ang BT, Wong J, Lee KK, Wang E, Ng I. Temporal changes in cerebral tissue oxygenation with cerebrovascular pressure reactivity in severe traumatic brain injury. J Neurol Neurosurg Psychiatry 2007; 78:298-302. [PMID: 17028122 PMCID: PMC2117644 DOI: 10.1136/jnnp.2005.082735] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the temporal relationship between cerebrovascular pressure reactivity and brain tissue oxygenation in patients with severe head injury. METHODS In 40 patients, brain tissue oxygenation and intracranial pressure were monitored. Time-averaged values for intracranial pressure (ICP), mean arterial pressure (MAP), cerebral perfusion pressure (CPP) and brain tissue oxygenation (PtiO2) were computed. The pressure reactivity index (PRx) was calculated. The mean values of the variables were obtained at the 6-h and 72-h post-injury time points, and the difference between the two time points for each of the variables was denoted as delta (delta). RESULTS Of the 40 patients, 32 were survivors and 8 were non-survivors. Statistically significant differences were present between these two groups with regard to deltaMAP (p = 0.013), ICP at 6 h (p = 0.027), CPP at 72 h (p = 0.018), deltaCPP (p = 0.033), PRx at 6 h (p = 0.029), PRx at 72 h (p = 0.002), PtiO2 at 72 h (p < 0.0005) and deltaPtiO2 (p = 0.023) values, reflecting an improvement with time in survivors and a deterioration with time in non-survivors. In non-survivors, the magnitude of change in PtiO2 and CPP with time correlated in a negative linear fashion (p = 0.042 and 0.029, respectively) with the change in PRx with time, whereas no such relationship was seen in survivors. CONCLUSION The severity of brain tissue oxygenation derangement correlates with increasing cerebrovascular dysautoregulation in patients succumbing to severe head injury, supporting the utility of PRx as a monitoring variable and the rationale for a target-driven approach to head injury management.
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Affiliation(s)
- B T Ang
- Acute Brain Injury Research Laboratory, Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore 308433, Singapore
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Abstract
The Domenico solution is widely used in several analytical models for simulating ground water contaminant transport scenarios. Unfortunately, many textbook as well as journal article treatments of this approximate solution are full of empirical statements that are developed without mathematical rigor. For this reason, a rigorous analysis of this solution is warranted. In this article, we present a mathematical method to derive the Domenico solution and explore its limits. Our analysis shows that the Domenico solution is a true analytical solution when the value of longitudinal dispersivity is zero. For nonzero longitudinal dispersivity values, the Domenico solution will introduce a finite amount of error. We use an example problem to quantify the nature of this error and suggest some general guidelines for the appropriate use of this solution.
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Affiliation(s)
- V Srinivasan
- Department of Civil Engineering, Auburn University, Auburn, AL 36849, USA.
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Lee LK, Chen PCY, Lee KK, Kaur J. Menstruation among adolescent girls in Malaysia: a cross-sectional school survey. Singapore Med J 2006; 47:869-74. [PMID: 16990962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
INTRODUCTION The onset of menstruation is part of the maturation process. However, variability in menstrual cycle characteristics and menstrual disorders are common. The purpose of this study was to determine the menstrual characteristics of adolescent females and factors associated with it. METHODS This is a cross-sectional descriptive study carried out on 2,411 secondary school adolescent females in Negeri Sembilan, Malaysia. Data were collected using a self-administered structured questionnaire on menstruation in Bahasa Malaysia. RESULTS Abnormal cycle length (menstrual cycle longer than 35 days or cycle length between 14 to 20 days or irregular pattern) was common and affected 37.2 percent of subjects. The majority (74.6 percent) experienced premenstrual syndrome and 69.4 percent had dysmenorrhoea. About 18 percent reported excessive menstrual loss (use two pads at a time to prevent blood from soaking through or confirmed by doctor to be anaemic due to heavy menstrual flow). Only 11.1 percent of schoolgirls seeked medical consultation for their menstrual disorders. Mothers remained the most important source of information (80 percent). Menstrual disorders were significantly more common in female adolescents who smoke and have suicidal behaviours (p-value is less than 0.05). CONCLUSION Menstrual problems among adolescent female are common. They are influenced by certain modifiable factors.
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Affiliation(s)
- L K Lee
- Department of Community Medicine, International Medical University, Plaza Komanwel, Bukit Jalil, Kuala Lumpur 57000, Malaysia.
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Lee LK, Chen PCY, Lee KK, Kaur J. Premarital sexual intercourse among adolescents in Malaysia: a cross-sectional Malaysian school survey. Singapore Med J 2006; 47:476-81. [PMID: 16752015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Sexual intercourse among Malaysian adolescents is a major concern, especially with the worry of HIV/AIDS. This study was done to determine the prevalence of sexual intercourse among secondary school students aged 12 to 19 years in Negeri Sembilan, Malaysia. METHODS This is a cross-sectional school survey conducted on 4,500 adolescent students based on a structured questionnaire. Data were collected using the self-administered questionnaire (translated version of the Youth Risk Behaviour Surveillance in Bahasa Malaysia). RESULTS The study showed that 5.4 percent of the total sample were reported to have had sexual intercourse. The proportion among male students who had had sex was higher (8.3 percent) compared with female students (2.9 percent). The mean age at first sexual intercourse was 15 years. One percent of students reported that they had been pregnant or had made someone else pregnant. Adolescent sexual intercourse was significantly associated with (1) socio-demographical factors (age, gender); (2) environmental factors (staying with parents); and (3) substance use (alcohol use, cigarette smoking, drug use), even after adjustment for demographical factors. The survey showed that 20.8 percent of respondents had taken alcohol, 14.0 percent had smoked cigarettes, 2.5 percent had tried marijuana, 1.2 percent had tried ecstasy pills, 2.6 percent had tried glue sniffing, 0.7 percent had tried heroin, and 0.7 percent had intravenous drugs. CONCLUSION Prevalence of sexual intercourse among Malaysian adolescents was relatively low compared to developed countries. However, certain groups of adolescents tend to be at higher risk of engaging in sexual intercourse. This problem should be addressed early by targeting these groups of high-risk adolescents.
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Affiliation(s)
- L K Lee
- Department of Community Medicine, International Medical University, Plaza Komanwel, Bukit Jalil, Kuala Lumpur 57000, Malaysia.
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Lee KK, Seow WT, Ng I. Demographical profiles of adult severe traumatic brain injury patients: implications for healthcare planning. Singapore Med J 2006; 47:31-6. [PMID: 16397718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION In Singapore, severe traumatic brain injury (TBI) continues to be a major public health problem and devastating condition, with significant mortality and morbidity. By understanding the incidence, prevalence and implications of severe TBI in Singapore, strategic plans to meet the unique needs of these patients in the local context may be developed. METHODS The demographical profiles of the adult severe TBI patients in Singapore were studied in this retrospective review of 528 patients admitted to the National Neuroscience Institute (NNI) from January 1999 to December 2003. RESULTS There were 420 male and 108 female patients, age ranging from 15 to 96 years old, with a mean and standard deviation (SD) of 44.6 +/- 19.9 years, admitted to NNI during the study period. Motor vehicle and fall-related accidents were the leading causes of severe TBI. Three high-risk groups identified were young adults, elderly, and foreign workers. CONCLUSION Preventive measures targeting at these high-risk groups are important to reduce the incidence of severe TBI.
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Affiliation(s)
- K K Lee
- Department of Nursing Administration, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433.
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Abstract
The aim of this study was to examine the effectiveness of Qi therapy (external Qigong) in the management of symptoms of advanced cancer in a man. We used a single case study design to evaluate the effectiveness of Qi therapy (external Qigong) in a 35-year-old man with advanced cancer (Stage IV) involving metastases in the stomach, lung and bone (Karnofsky performance scale: KPS, 40: requires special care and assistance, disabled). Treatment involved six days of pre-assessment, eight treatment sessions on alternate days over 16 days, and a two-week follow-up phase. A visual analogue scale (VAS) was used to assess the patient's self-reported symptoms of cancer over the intervention and follow-up periods. Following treatment, VAS scores' analysis revealed beneficial effects on pain, vomiting, dyspnoea, fatigue, anorexia, insomnia, daily activity and psychological calmness. These improvements were maintained over the two-week follow-up phase. After the first Qi therapy session, the patient discontinued medication and could sit by himself; after the fourth session, the patient was able to walk and use the toilet without assistance (improvement in KPS: 70: care for self, unable to perform normal activity or to do active work). Although limited by the single case study approach, our results support previous studies on this topic and provide reasons to conduct controlled clinical trials.
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Affiliation(s)
- M S Lee
- Center for Integrative Medicine, Institute of Medical Science, Wonkwang University, Iksan, Korea.
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Lee KK, Carlson S, Pratt M, Kohl H. 018: Prevalence of Meeting Physical Activity Recommendations as a Predictor of State Obesity Prevalence - United States, 2003. Am J Epidemiol 2005. [DOI: 10.1093/aje/161.supplement_1.s5a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- K K Lee
- Centers for Disease Control and Prevention - CDC, Atlanta, GA, 30341
| | - S Carlson
- Centers for Disease Control and Prevention - CDC, Atlanta, GA, 30341
| | - M Pratt
- Centers for Disease Control and Prevention - CDC, Atlanta, GA, 30341
| | - H Kohl
- Centers for Disease Control and Prevention - CDC, Atlanta, GA, 30341
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Lee KK, Prochasson P, Florens L, Swanson SK, Washburn MP, Workman JL. Proteomic analysis of chromatin-modifying complexes in Saccharomyces cerevisiae identifies novel subunits. Biochem Soc Trans 2005; 32:899-903. [PMID: 15506919 DOI: 10.1042/bst0320899] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Epigenetics is the alteration of phenotype without affecting the genotype. An underlying molecular mechanism of epigenetics is the changes of chromatin structure by covalent histone modifications and nucleosome reorganization. In the yeast, Saccharomyces cerevisiae, two of the most well-studied macromolecular complexes that perform these epigenetic changes are the ATP-dependent Swi/Snf chromatin-remodelling complex and the SAGA histone acetyltransferase complex. To understand fully the mechanism by which these large protein complexes perform their functions in the cell, it is crucial that all the subunits of these complexes are identified. In an attempt to identify new subunits associated with SAGA and Swi/Snf, we used tandem affinity purification, followed by a multidimensional protein identification technology to analyse the subunit composition. Our analysis identified two novel proteins, one associated with SAGA, YPL047W (Sgf11), and another associated with Swi/Snf, Rtt102.
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Affiliation(s)
- K K Lee
- Stowers Institute for Medical Research, 1000 E. 50th Kansas City, MO 64110, USA
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Abstract
Cerebral ischemia is one of the most important causes of secondary insults following acute brain injury. While intracranial pressure monitoring in the intensive care unit constitutes the cornerstone of neurocritical care monitoring, it does not reflect the state of oxygenation of the injured brain. The holy grail of neuromonitoring is a modality that would reflect accurately real time the status of oxygenation in the tissue of interest, is robust, artefact free and that which provides information that can be used for therapeutic interventions and to improve outcome. Such a device could conceivably be used to augment the sensitivity of current multi-modality monitoring systems in the neurocritical management of brain injured patients. This article examines the availability of data in the literature to support clinical use of local tissue oxygen probes in intensive care.
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Affiliation(s)
- I Ng
- Acute Brain Injury Research Laboratory, Department of Neurosurgery, National Neuroscience Institute, TTSH Campus, Singapore.
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Lee KK, Teo EC. Effects of laminectomy and facetectomy on the stability of the lumbar motion segment. Med Eng Phys 2004; 26:183-92. [PMID: 14984840 DOI: 10.1016/j.medengphy.2003.11.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2003] [Revised: 10/31/2003] [Accepted: 11/21/2003] [Indexed: 10/26/2022]
Abstract
A ligamentous, nonlinear, sliding contact, three-dimensional finite element (FE) model of L2-L3 complex was developed to investigate the biomechanical effect of laminectomy with and without facetectomy. The L2-L3 FE model was validated against experimental study under various physiological loadings and found to match well with the experimental data. Four iatrogenic models (unilateral laminectomy, unilateral laminectomy with unilateral facetectomy, unilateral laminectomy with bilateral facetectomy and total bilateral laminectomy) were evaluated under flexion, extension, torsion, lateral bending, anterior and posterior shear load vectors to determine alterations in kinematics and annulus stress. Results show that total laminectomy with facetectomy induces considerable increase in motion and annulus stress, except for lateral bending, whereas unilateral laminectomy shows the least increases.
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Affiliation(s)
- K K Lee
- School of Mechanical and Production Engineering, Nanyang Technological University, 50 Nanyang Avenue, 639798 Singapore
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