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Astbury S, Baskar A, Grove JI, Kaye P, Aravinthan AD, James MW, Clarke C, Aithal GP, Venkatachalapathy SV. Next-generation sequencing of pancreatic cyst wall specimens obtained using micro-forceps for improving diagnostic accuracy. Endosc Int Open 2023; 11:E983-E991. [PMID: 37941539 PMCID: PMC10629470 DOI: 10.1055/a-2163-8805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/15/2023] [Indexed: 11/10/2023] Open
Abstract
Background and study aims Pancreatic cysts are common incidental findings, with an estimated prevalence of 13% to 15% in imaging done for other reasons. Diagnosis often relies on collection of cyst fluid, but tissue sampling using micro-forceps may allow for a more reliable diagnosis and higher yield of DNA for next-generation sequencing (NGS). The primary aim was to assess the performance of NGS in identifying mucinous cyst. The secondary aims were to assess DNA yield between the cyst fluid and cyst wall tissue, complication rate and performance of conventional investigations. Patients and methods Twenty-four patients referred for endoscopic ultrasound were recruited. Biopsies were taken using micro-forceps and the AmpliSeq Cancer Hotspot panel was used for NGS, a polymerase chain reaction assay targeting several hotspots within 50 genes, including GNAS , KRAS and VHL . Results The concentration of DNA extracted from 24 cyst wall samples was significantly higher than in the nine of 24 available matched cyst fluid samples. The sensitivity, specificity, and diagnostic accuracy of NGS for diagnosing mucinous cyst were 93%, 50% and 84%; for standard of care, they were -66.6%, 50% and 63.1%; and for standard of care with NGS, they were 100%, 50%, and 89.4% respectively. Cyst wall biopsy was able to diagnose 19 of 24 cysts (4 high risk, 7 intraductal papillary mucinous neoplasms, 4 cysts of mucinous origin, and 4 benign). Conclusions NGS data correlate well with histology and may aid in diagnosis and risk stratification of pancreatic cysts. Cyst wall biopsy performs well in diagnosing cysts but was inadequate in five of 24 patients.
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Affiliation(s)
- Stuart Astbury
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Aishwarya Baskar
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jane I. Grove
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Philip Kaye
- Department of Pathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Aloysious D. Aravinthan
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Martin W. James
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Christopher Clarke
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Guruprasad P. Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Suresh Vasan Venkatachalapathy
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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Bawden SJ, Hoad C, Kaye P, Stephenson M, Dolman G, James MW, Wilkes E, Austin A, Guha IN, Francis S, Gowland P, Aithal GP. Comparing magnetic resonance liver fat fraction measurements with histology in fibrosis: the difference between proton density fat fraction and tissue mass fat fraction. MAGMA 2023; 36:553-563. [PMID: 36538248 PMCID: PMC10468948 DOI: 10.1007/s10334-022-01052-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Magnetic resonance spectroscopy (MRS) provides a powerful method of measuring fat fraction. However, previous studies have shown that MRS results give lower values compared with visual estimates from biopsies in fibrotic livers. This study investigated these discrepancies and considered whether a tissue water content correction, as assessed by MRI relaxometry, could provide better agreement. MATERIALS AND METHODS 110 patients were scanned in a 1.5 T Philips scanner and biopsies were obtained. Multiple echo MRS (30 × 30 × 30 mm volume) was used to determine Proton Density Fat Fraction (PDFF). Biopsies were assessed by visual assessment for fibrosis and steatosis grading. Digital image analysis (DIA) was also used to quantify fat fraction within tissue samples. T1 relaxation times were then used to estimate tissue water content to correct PDFF for confounding factors. RESULTS PDFF values across the four visually assessed steatosis grades were significantly less in the higher fibrosis group (F3-F4) compared to the lower fibrosis group (F0-F2). The slope of the linear regression of PDFF vs DIA fat fraction was ~ 1 in the low fibrosis group and 0.77 in the high fibrosis group. Correcting for water content based on T1 increased the gradient but it did not reach unity. DISCUSSION In fibrotic livers, PDFF underestimated fat fraction compared to DIA methods. Values were improved by applying a water content correction, but fat fractions were still underestimated.
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Affiliation(s)
- Stephen James Bawden
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2RD, UK.
- Sir Peter Mansfield Imaging Centre, SPMIC, University Park, Physics and Astronomy, University of Nottingham, Nottingham, UK.
| | - Caroline Hoad
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2RD, UK
| | - Philip Kaye
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2RD, UK
- Department of Cellular Pathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mary Stephenson
- Clinical Imaging Research Centre (CIRC), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Grace Dolman
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2RD, UK
| | - Martin W James
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2RD, UK
| | - Emilie Wilkes
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2RD, UK
| | | | - Indra Neil Guha
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2RD, UK
| | - Susan Francis
- Sir Peter Mansfield Imaging Centre, SPMIC, University Park, Physics and Astronomy, University of Nottingham, Nottingham, UK
| | - Penny Gowland
- Sir Peter Mansfield Imaging Centre, SPMIC, University Park, Physics and Astronomy, University of Nottingham, Nottingham, UK
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2RD, UK
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3
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Stassen PMC, Goodchild G, de Jonge PJF, Erler NS, Anderloni A, Cennamo V, Church NI, Fernandez-Urien Sainz I, Huggett MT, James MW, Joshi D, Kylänpää L, Laleman W, Nayar MK, Oppong KW, Poley JW, Potts JR, Repici A, Udd M, Vila JJ, Wong T, Bruno MJ, Webster GJM. Diagnostic accuracy and interobserver agreement of digital single-operator cholangioscopy for indeterminate biliary strictures. Gastrointest Endosc 2021; 94:1059-1068. [PMID: 34216597 DOI: 10.1016/j.gie.2021.06.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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] [Received: 01/18/2021] [Accepted: 06/22/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Digital single-operator cholangioscopy (d-SOC) with cholangioscopic biopsy sampling has shown promise in the evaluation of indeterminate biliary strictures. Some studies have suggested higher sensitivity for visual impression compared with biopsy sampling, although assessors were not blinded to previous investigations. We aimed to investigate the diagnostic accuracy and interobserver agreement (IOA) of d-SOC in the visual appraisal of biliary strictures when blinded to additional information. METHODS A multicenter, international cohort study was performed. Cholangioscopic videos in patients with a known final diagnosis were systematically scored. Pseudonymized videos were reviewed by 19 experts in 2 steps: blinded for patient history and investigations and unblinded. RESULTS Forty-four high-quality videos were reviewed of 19 benign and 25 malignant strictures. The sensitivity and specificity for the diagnosis of malignancy was 74.2% and 46.9% (blinded) and 72.7% and 62.5% (unblinded). Cholangioscopic certainty of a malignant diagnosis led to overdiagnosis (sensitivity, 90.6%; specificity, 33%), especially if no additional information was provided. The IOA for the presence of malignancy was fair for both assessments (Fleiss' κ = .245 [blinded] and κ = .321 [unblended]). For individual visual features, the IOA ranged from slight to moderate for both assessments (κ = .059-.400 vs κ = .031-.452). CONCLUSIONS This study showed low sensitivity and specificity for blinded and unblinded d-SOC video appraisal of indeterminate biliary strictures, with considerable interobserver variation. Although reaching a consensus on the optical features of biliary strictures remains important, optimizing visually directed biopsy sampling may be the most important role of cholangioscopy in biliary stricture assessment.
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Affiliation(s)
- Pauline M C Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - George Goodchild
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center, Milan, Italy
| | - Vincenzo Cennamo
- Gastroenterology and Interventional Endoscopy Unit, Local Health Authority of Bologna, Bologna, Italy
| | - Nicholas I Church
- Department of Gastroenterology and Hepatology, Lothian University Hospitals NHS Trust, Edinburgh, UK
| | | | - Matthew T Huggett
- Department of Gastroenterology, St James's University Hospital, Leeds, UK
| | - Martin W James
- Nottingham Digestive Disease Centre (NDDC) and NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Leena Kylänpää
- Department of Gastroenterological surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Manu K Nayar
- HPB Unit Newcastle upon Tyne Hospitals, and Translational and Clinical Research Institute Newcastle University, Newcastle, UK
| | - Kofi W Oppong
- HPB Unit Newcastle upon Tyne Hospitals, and Translational and Clinical Research Institute Newcastle University, Newcastle, UK
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Marianne Udd
- Department of Gastroenterological surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juan J Vila
- Department of Gastroenterology and Hepatology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Terence Wong
- Department of Gastroenterology and Hepatology, Guys and St Thomas' Hospital, London, UK
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - George J M Webster
- Department of Gastroenterology, University College London Hospitals, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
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Venkatachalapathy SV, James MW, Huggett MT, Paranandi B, Pereira SP, Johnson G, Aravinthan AD, Aithal GP. Utility of palliative EUS-guided biliary drainage using lumen-apposing metal stents: a prospective multicenter feasibility study (with video). Gastrointest Endosc 2021; 94:321-328. [PMID: 33545136 DOI: 10.1016/j.gie.2021.01.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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] [Received: 08/15/2020] [Accepted: 01/24/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Biliary drainage with ERCP is successful in only 80% to 90% of cases of extrahepatic cholangiocarcinoma and pancreatic cancer. We present the results of a multicenter prospective study assessing the safety, feasibility, and quality of life of patients after EUS-guided biliary drainage (EUS-BD) with lumen-apposing metal stents after failed ERCP. METHODS All consecutive adults with a dilated common bile duct (CBD) ≥14 mm secondary to inoperable malignant distal CBD stricture and failed ERCP biliary drainage were screened and recruited from 3 tertiary UK centers. Technical success of EUS-BD using lumen-apposing metal stents was the primary endpoint. Improvement in serum bilirubin level, 30-day mortality, procedure-related adverse events, and quality of life were secondary endpoints. Improvement in quality of life was measured using a validated questionnaire (EORTC QLQ-BIL21). RESULTS Twenty patients were included in the analysis. EUS-BD was technically successful in all patients and the clinical success rate was 95% (19 of 20) at day 7 (>50% reduction in bilirubin level) and 92.3% (12 of 13) at day 30 (bilirubin <50 μmol/L). There were significant improvements in overall quality of life score (49 vs 42, P = .03) at day 30. All-cause 30-day mortality was 20% and the moderate adverse event rate was 10% (1 cholangitis and 1 stent migration). CONCLUSION EUS-BD has acceptable technical success and safety as a second-line palliative treatment for inoperable malignant distal CBD strictures. Randomized controlled studies comparing EUS-BD with percutaneous transhepatic biliary drainage are needed to determine their effectiveness in clinical practice. (ISCRTN registration number: ISRCTN13196704.).
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Affiliation(s)
- Suresh Vasan Venkatachalapathy
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - Martin W James
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - Matthew T Huggett
- Leeds Teaching Hospitals NHS Trust - Gastroenterology, Leeds, United Kingdom
| | - Bharat Paranandi
- Leeds Teaching Hospitals NHS Trust - Gastroenterology, Leeds, United Kingdom
| | - Stephen P Pereira
- UCL Institute for Liver & Digestive Health, University College London, London, United Kingdom; Department of Gastroenterology, University College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Gavin Johnson
- Department of Gastroenterology, University College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Aloysious D Aravinthan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom; Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom; Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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5
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Tsien C, Tan H, Sharma S, Palaniyappan N, Wijayasiri P, Leung K, Hayre J, Mowlem E, Kang R, Eddowes PJ, Wilkes E, Venkatachalapathy SV, Guha IN, Antonova L, Cheung AC, Griffiths WJ, Butler AJ, Ryder SD, James MW, Aithal GP, Aravinthan AD. Long-term outcomes of liver transplant recipients followed up in non-transplant centres: Care closer to home. Clin Med (Lond) 2021; 21:e32-e38. [PMID: 33479081 DOI: 10.7861/clinmed.2020-0609] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Increasing rates of liver transplantation and improved outcomes have led to greater numbers of transplant recipients followed up in non-transplant centres. Our aim was to document long-term clinical outcomes of liver transplant recipients managed in this 'hub-and-spoke' healthcare model. METHODS A retrospective analysis of all adult patients who underwent liver transplantation between 1987 and 2016, with post-transplant follow-up in two non-transplant centres in the UK (Nottingham) and Canada (Ottawa), was performed. RESULTS The 1-, 5-, 10- and 20-year patient survival rates were 98%, 95%, 87% and 62%, and 100%, 96%, 88% and 62% in the Nottingham and Ottawa groups, respectively (p=0.87). There were no significant differences between the two centres in 1-, 5-, 10- and 20-year cumulative incidence of death-censored graft-survival (p=0.10), end-stage renal disease (p=0.29) or de novo cancer (p=0.22). Nottingham had a lower incidence of major cardiovascular events (p=0.008). CONCLUSION Adopting a new model of healthcare provides a means of delivering post-transplant patient care close to home without compromising patient survival and long-term clinical outcomes.
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Affiliation(s)
- Cynthia Tsien
- The Ottawa Hospital, Ottawa, Canada, University of Ottawa, Ottawa, Canada and Ottawa Hospital Research Institute, Ottawa, Canada
| | - Huey Tan
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | | | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Pramudi Wijayasiri
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | | | | | | | | | - Peter J Eddowes
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Emilie Wilkes
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Suresh V Venkatachalapathy
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Indra N Guha
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | | | - Angela C Cheung
- The Ottawa Hospital, Ottawa, Canada, University of Ottawa, Ottawa, Canada and Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Stephen D Ryder
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Martin W James
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Aloysious D Aravinthan
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
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Chow CW, Haider SA, Ragunath K, Aithal GP, James MW, Ortiz-Fernandez-Sordo J, Aravinthan AD, Venkatachalapathy SV. Comparison of the reverse bevel versus Franseen type endoscopic ultrasound needle. World J Gastrointest Endosc 2020; 12:266-275. [PMID: 32994857 PMCID: PMC7503614 DOI: 10.4253/wjge.v12.i9.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/08/2020] [Accepted: 08/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Reverse bevel (RB) needle is widely used for endoscopic ultrasound fine needle biopsy (EUS-FNB). A 3-plane symmetrical needle with Franseen geometry (FG) has recently become available.
AIM To compare the clinical efficacy of FG to that of RB needle.
METHODS A retrospective cohort study of all adult patients who underwent EUS-FNB for solid and mixed lesions either with 22G RB needle or 22G FG needle between January 2016 and February 2019 was undertaken. All cytology slides were reviewed by an independent gastrointestinal cytopathologist blinded to the needle used and the initial cytology report. The primary and secondary outcomes were to assess the sample adequacy using Euro-cytology criteria and the number of cell clusters, respectively.
RESULTS Two hundred and twenty six procedures were included in the study. RB needle was used in 128 procedures and FG needle in 98 procedures. The baseline characteristics of both groups were comparable. On multivariable analysis, FG needle (P = 0.02) and location of the lesion (P < 0.01) were independently associated with adequate tissue. Further, the use of FG needle (P = 0.04) and the size of the lesion (P = 0.02) were independently associated with acquisition of increased number of cell clusters.
CONCLUSION FG needle is superior to RB needle in acquiring adequate tissue and attaining higher number of cell clusters for solid and mixed lesions.
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Affiliation(s)
- Chi Wing Chow
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals National Health Service Trust and University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Syeda Asma Haider
- Department of Pathology, Nottingham University Hospitals National Health Service Trust, Nottingham NG7 2UH, United Kingdom
| | - Krish Ragunath
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals National Health Service Trust and University of Nottingham, Nottingham NG7 2UH, United Kingdom
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Guruprasad P Aithal
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals National Health Service Trust and University of Nottingham, Nottingham NG7 2UH, United Kingdom
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Martin W James
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals National Health Service Trust and University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Jacobo Ortiz-Fernandez-Sordo
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals National Health Service Trust and University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Aloysious Dominic Aravinthan
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals National Health Service Trust and University of Nottingham, Nottingham NG7 2UH, United Kingdom
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Suresh Vasan Venkatachalapathy
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals National Health Service Trust and University of Nottingham, Nottingham NG2 7UH, United Kingdom
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Abstract
By 2020, chronic liver disease will have eclipsed ischaemic heart disease as the leading cause of working life years lost in the UK. As mortality from chronic liver disease continues to rise, the landscape of aetiology has shifted from infectious to non-communicable causes. In parallel with the growing prevalence of obesity and type 2 diabetes, non-alcoholic fatty liver disease is estimated to affect 25% of the UK adult population. Simultaneously, escalating alcohol consumption has fuelled public health and economic concerns regarding its widespread impact on working-age adults. Given that chronic liver disease remains clinically silent until its advanced stages, there is an urgent unmet need to identify affected individuals earlier in the disease process, enabling targeted intervention strategies which may improve prognosis. Robust epidemiological data have shown that liver fibrosis is the strongest predictor of clinically meaningful outcomes, including decompensation, liver cancer and overall mortality. Detecting fibrosis among at-risk individuals, in a manner that is reproducible, non-invasive, safe and cost effective, has become a major challenge of our time. This article addresses the pitfalls of the standard panel of liver function tests, discusses other non-invasive biomarkers and reviews imaging technologies which may revolutionise community-based diagnosis and stratification of chronic liver disease.
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Affiliation(s)
- Prarthana Thiagarajan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.,University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, Nottingham, UK
| | - Jane Chalmers
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.,University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, Nottingham, UK
| | - Indra N Guha
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.,University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, Nottingham, UK
| | - Martin W James
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.,University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, Nottingham, UK
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8
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Bradley CR, Cox EF, Scott RA, James MW, Kaye P, Aithal GP, Francis ST, Guha IN. Multi-organ assessment of compensated cirrhosis patients using quantitative magnetic resonance imaging. J Hepatol 2018; 69:1015-1024. [PMID: 29886155 DOI: 10.1016/j.jhep.2018.05.037] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Advancing liver disease results in deleterious changes in a number of critical organs. The ability to measure structure, blood flow and tissue perfusion within multiple organs in a single scan has implications for determining the balance of benefit vs. harm for therapies. Our aim was to establish the feasibility of magnetic resonance imaging (MRI) to assess changes in Compensated Cirrhosis (CC), and relate this to disease severity and future liver-related outcomes (LROs). METHODS A total of 60 patients with CC, 40 healthy volunteers and 7 patients with decompensated cirrhosis were recruited. In a single scan session, MRI measures comprised phase-contrast MRI vessel blood flow, arterial spin labelling tissue perfusion, T1 longitudinal relaxation time, heart rate, cardiac index, and volume assessment of the liver, spleen and kidneys. We explored the association between MRI parameters and disease severity, analysing differences in baseline MRI parameters in the 11 (18%) patients with CC who experienced future LROs. RESULTS In the liver, compositional changes were reflected by increased T1 in progressive disease (p <0.001) and an increase in liver volume in CC (p = 0.006), with associated progressive reduction in liver (p <0.001) and splenic (p <0.001) perfusion. A significant reduction in renal cortex T1 and increase in cardiac index and superior mesenteric arterial blood flow was seen with increasing disease severity. Baseline liver T1 (p = 0.01), liver perfusion (p <0.01), and renal cortex T1 (p <0.01) were significantly different in patients with CC who subsequently developed negative LROs. CONCLUSIONS MRI enables the contemporaneous assessment of organs in liver cirrhosis in a single scan without the requirement for a contrast agent. MRI parameters of liver T1, renal T1, hepatic and splenic perfusion, and superior mesenteric arterial blood flow were related to the risk of LROs. LAY SUMMARY This study assesses the changes to structure, blood flow and perfusion that occur in the key organs (liver, spleen and kidney) associated with severe liver disease (Compensated Cirrhosis), using magnetic resonance imaging. The magnetic resonance imaging measures which changed with disease severity and were related to negative liver-related clinical outcomes are described.
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Affiliation(s)
- Christopher R Bradley
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK; NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Eleanor F Cox
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK; NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Robert A Scott
- NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Martin W James
- NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Phillip Kaye
- NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Guruprasad P Aithal
- NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK; Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Susan T Francis
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK; NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Indra Neil Guha
- NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK; Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK.
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9
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Kasi M, Rashid S, Wallace SAJ, Sujendran V, Griffiths B, Butler A, Gibbs P, Sreedharan L, Zaitoun AM, Venkatachalapathy S, James MW, Aithal GP. Seeding of hepatocellular carcinoma into the stomach wall following endoscopic ultrasound and fine-needle aspiration biopsy. Oxf Med Case Reports 2018; 2018:omy039. [PMID: 30046450 PMCID: PMC6053806 DOI: 10.1093/omcr/omy039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 04/26/2018] [Accepted: 06/01/2018] [Indexed: 01/10/2023] Open
Abstract
Delayed gastrointestinal metastasis is a rare complication of hepatocellular carcinoma (HCC). We present the case of a patient who presented with melaena and microcytic anaemia 6 years after receiving an orthotopic liver transplant for hepatitis B-induced HCC. Oesophagogastroduodenoscopy revealed a fungating gastric mass at the lesser curve and histology from biopsies confirmed metastatic recurrence of HCC in the stomach. The route of metastasis is likely due to iatrogenic seeding of tumour cells during pre-transplant endoscopic ultrasound (EUS) and fine needle aspiration (FNA) biopsy. Subsequent positron emission tomography and magnetic resonance imaging failed to reveal further metastatic disease and the patient was managed with a total gastrectomy. This is the first reported description in the literature of needle-track metastasis in the stomach due to liver EUS-FNA for HCC.
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Affiliation(s)
- M Kasi
- Nottingham Digestive Diseases Centre (NDDC) and NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Samin Rashid
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - S A J Wallace
- Division of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Vijayendran Sujendran
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Bill Griffiths
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Andrew Butler
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Paul Gibbs
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Loveena Sreedharan
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - A M Zaitoun
- Division of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Venkatachalapathy
- Nottingham Digestive Diseases Centre (NDDC) and NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - M W James
- Nottingham Digestive Diseases Centre (NDDC) and NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - G P Aithal
- Nottingham Digestive Diseases Centre (NDDC) and NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Nottingham, UK
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10
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Fateen W, Taylor N, James MW. Impact of Cholangioscopy: Diagnosing Sclerosing Cholangitis-Associated Biliary Calculi not Detected Using MRI and Endoscopic Ultrasound. Ann Hepatol 2018; 17:330-331. [PMID: 29469039 DOI: 10.5604/01.3001.0010.8664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Waleed Fateen
- National Institute for Health Research (NIHR) Biomedical Research Centre in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham
| | - Nick Taylor
- Derby Digestive Disease Centre, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Martin W James
- National Institute for Health Research (NIHR) Biomedical Research Centre in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham
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11
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Harman DJ, Ryder SD, James MW, Wilkes EA, Card TR, Aithal GP, Guha IN. Obesity and type 2 diabetes are important risk factors underlying previously undiagnosed cirrhosis in general practice: a cross-sectional study using transient elastography. Aliment Pharmacol Ther 2018; 47:504-515. [PMID: 29210096 DOI: 10.1111/apt.14463] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [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: 05/16/2017] [Revised: 07/03/2017] [Accepted: 11/19/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rising cirrhosis incidence and mortality in the United Kingdom has been attributed predominantly to excess alcohol consumption. However, metabolic risk factors such as Type 2 diabetes and obesity may also be important. AIM To screen at-risk individuals in general practice for undetected cirrhosis using transient elastography and study the risk factors underlying these cases. METHODS The study was undertaken in 4 general practices (adult patient population 20 868) between February 2012 and September 2014. Patients with defined risk factors for chronic liver disease (hazardous alcohol use and/or Type 2 diabetes) were identified from the General Practice electronic records and invited for transient elastography. Elevated liver stiffness was defined as ≥8 kPa. Cirrhosis was confirmed by established histological, radiological and biochemical methods. RESULTS Two thousand three hundred and sixty eight patients were invited for transient elastography and 899/919 who attended (97.8%) had valid measurements. Of these 230 patients had elevated liver stiffness (25.6%) and 27 had cirrhosis (2.9%). Risk factors for new cirrhosis diagnoses were obesity and/or Type 2 diabetes in 16 patients (59.3%), alcohol alone in 3 (11.1%) and both alcohol and obesity and/or diabetes in eight (29.6%). Presence of cirrhosis was significantly increased in obese patients with Type 2 diabetes or hazardous alcohol use compared to non-obese (odds ratio 9.4 [95% CI 2.2-40.9] and 5.6 [95% CI 1.6-19.7] respectively). CONCLUSIONS The number of new cases of cirrhosis diagnosed clearly demonstrates that existing estimates of prevalence are likely to be gross underestimates. Obesity was an important risk factor for cirrhosis within both alcohol users and diabetics.
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Affiliation(s)
- D J Harman
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK
| | - S D Ryder
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK
| | - M W James
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK
| | - E A Wilkes
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK
| | - T R Card
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK.,Division of Epidemiology and Public Health, City Hospital Campus, University of Nottingham, Nottingham, UK
| | - G P Aithal
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - I N Guha
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
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12
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Fateen W, Khan F, O'Neill RJ, James MW, Ryder SD, Aithal GP. Healthcare costs of transarterial chemoembolization in the treatment of hepatocellular carcinoma. J Hepatocell Carcinoma 2017; 4:123-130. [PMID: 29082223 PMCID: PMC5652915 DOI: 10.2147/jhc.s144068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background A meta-analysis comparing drug-eluting beads transarterial chemoembolization (DEB-TACE) with conventional transarterial chemoembolization (cTACE) has recently been published. On balance, no significant differences were found in terms of objective response and overall survival. The impact on healthcare costs had been studied in small series based on a hypothetical model and was in favor of DEB-TACE. We aimed to evaluate and compare health-care costs and effectiveness of both modalities in a cohort of patients from Nottingham, UK. Methods Using a dedicated radiology database, we identified all patients who had undergone cTACE or DEB-TACE between 2006 and 2012 at a single tertiary referral center based in Nottingham. We collected clinical data, including treatment response, postprocedure complications and 30-day mortality. Costing models were constructed to present both our local hospital perspective as well as the national health service position. Results During our study period, 101 procedures were performed on 43 patients (76 cTACE procedures on 26 patients and 25 DEB-TACE procedures on 17 patients). Overall, 11/26 in cTACE and 5/17 in DEB-TACE group had progressive disease (p=0.52). Adverse events were seen in 6/76 cTACE compared with 7/25 DEB-TACE group (p=0.16). Based on the predetermined standard pathway there was an unadjusted average cost difference of £3770.30 (TACE =£9070.44, DEB-TACE =£5300.14) in favor of the DEB-TACE. Results from our costing models indicated a £2715.33 (95% CI £580.88–4849.77) cost difference in favor of the same procedure. Conclusions Even when the extra costs of DEB-TACE were considered, the overall treatment costs per patient were lower in relation to cTACE.
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Affiliation(s)
- Waleed Fateen
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham.,Nottingham Digestive Diseases Centre, University of Nottingham
| | - Farooq Khan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham
| | - Richard J O'Neill
- Department of Radiology, Nottingham University Hospitals, NHS Trust, Nottingham, UK
| | - Martin W James
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham
| | - Stephen D Ryder
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham
| | - Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham.,Nottingham Digestive Diseases Centre, University of Nottingham
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13
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Meyer T, Fox R, Ma YT, Ross PJ, James MW, Sturgess R, Stubbs C, Stocken DD, Wall L, Watkinson A, Hacking N, Evans TRJ, Collins P, Hubner RA, Cunningham D, Primrose JN, Johnson PJ, Palmer DH. Sorafenib in combination with transarterial chemoembolisation in patients with unresectable hepatocellular carcinoma (TACE 2): a randomised placebo-controlled, double-blind, phase 3 trial. Lancet Gastroenterol Hepatol 2017; 2:565-575. [PMID: 28648803 DOI: 10.1016/s2468-1253(17)30156-5] [Citation(s) in RCA: 261] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transarterial chemoembolisation (TACE) is the standard of care for patients with intermediate stage hepatocellular carcinoma, while the multikinase inhibitor sorafenib improves survival in patients with advanced disease. We aimed to determine whether TACE with sorafenib improves progression-free survival versus TACE with placebo. METHODS We did a multicentre, randomised, placebo-controlled, phase 3 trial (TACE 2) in 20 hospitals in the UK for patients with unresectable, liver-confined hepatocellular carcinoma. Patients were eligible if they were at least aged 18 years, had Eastern Cooperative Oncology Group performance status of 1 or less, and had Child-Pugh A liver disease. Patients were randomised 1:1 by computerised minimisation algorithm to continuous oral sorafenib (400 mg twice-daily) or matching placebo combined with TACE using drug-eluting beads (DEB-TACE), which was given via the hepatic artery 2-5 weeks after randomisation and according to radiological response and patient tolerance thereafter. Patients were stratified according to randomising centre and serum α-fetoprotein concentration (<400 ng/mL and ≥400 ng/mL). Only the trial coordinator was unmasked to treatment allocation before patient progression during the study. The primary endpoint was progression-free survival defined as the interval between randomisation and progression according to Response Evaluation Criteria In Solid Tumors version 1.1 (RECIST v1.1) or death due to any cause, and was analysed by intention-to-treat. Safety was analysed by intention-to-treat. The trial has been completed and the final results are reported. The trial is registered at EudraCT, number 2008-005073-36, and ISRCTN, number ISRCTN93375053. FINDINGS Between Nov 4, 2010, and Dec 7, 2015, the trial enrolled 399 patients and was terminated after a planned interim futility analysis. 86 patients failed screening and 313 remaining patients were randomly assigned: 157 to sorafenib and 156 to placebo. The median daily dose was 660 mg (IQR 389·2-800·0) sorafenib versus 800 mg (758·2-800·0) placebo, and median duration of therapy was 120·0 days (IQR 43·0-266·0) for sorafenib versus 162·0 days (70·0-323·5) for placebo. There was no evidence of difference in progression-free survival between the sorafenib group and the placebo group (hazard ratio [HR] 0·99 [95% CI 0·77-1·27], p=0·94); median progression-free survival was 238·0 days (95% CI 221·0-281·0) in the sorafenib group and 235·0 days (209·0-322·0) in the placebo group. The most common grade 3-4 adverse events were fatigue (29 [18%] of 157 patients in the sorafenib group vs 21 [13%] of 156 patients in the placebo group), abdominal pain (20 [13%] vs 12 [8%]), diarrhoea (16 [10%] vs four [3%]), gastrointestinal disorders (18 [11%] vs 12 [8%]), and hand-foot skin reaction (12 [8%] and none). At least one serious adverse event was reported in 65 (41%) of 157 patients in the sorafenib group and 50 (32%) of 156 in the placebo group, and 181 serious adverse events were reported in total, 95 (52%) in the sorafenib group and 86 (48%) in the placebo group. Three deaths occurred in each group that were attributed to DEB-TACE. Four deaths were attributed to study drug; three in the sorafenib group and one in the placebo group. INTERPRETATION The addition of sorafenib to DEB-TACE does not improve progression-free survival in European patients with hepatocellular carcinoma. Alternative systemic therapies need to be assessed in combination with TACE to improve patient outcomes. FUNDING Bayer PLC and BTG PLC.
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Affiliation(s)
- Tim Meyer
- UCL Cancer Institute, University College London, UK; Royal Free London NHS Foundation Trust, London, UK.
| | - Richard Fox
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | | | - Paul J Ross
- Guy's Hospital, London, UK; King's College Hospital, London, UK
| | - Martin W James
- Guy's Hospital, London, UK; Nottingham University Hospitals NIHR BRC, Nottingham, UK
| | | | - Clive Stubbs
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - Deborah D Stocken
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Lucy Wall
- Western General Hospital, Edinburgh, UK
| | | | - Nigel Hacking
- Southampton University Hospitals NHS Trust, Southampton, UK
| | | | | | | | - David Cunningham
- The Royal Marsden NHS Foundation Trust, Sutton and London Hospital, Sutton, UK
| | | | | | - Daniel H Palmer
- University of Liverpool, Liverpool, UK; Clatterbridge Cancer Centre, Liverpool, UK
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14
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Jairath V, Kahan BC, Gray A, Doré CJ, Mora A, James MW, Stanley AJ, Everett SM, Bailey AA, Dallal H, Greenaway J, Le Jeune I, Darwent M, Church N, Reckless I, Hodge R, Dyer C, Meredith S, Llewelyn C, Palmer KR, Logan RF, Travis SP, Walsh TS, Murphy MF. Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TRIGGER): a pragmatic, open-label, cluster randomised feasibility trial. Lancet 2015; 386:137-44. [PMID: 25956718 DOI: 10.1016/s0140-6736(14)61999-1] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transfusion thresholds for acute upper gastrointestinal bleeding are controversial. So far, only three small, underpowered studies and one single-centre trial have been done. Findings from the single-centre trial showed reduced mortality with restrictive red blood cell (RBC) transfusion. We aimed to assess whether a multicentre, cluster randomised trial is a feasible method to substantiate or refute this finding. METHODS In this pragmatic, open-label, cluster randomised feasibility trial, done in six university hospitals in the UK, we enrolled all patients aged 18 years or older with new presentations of acute upper gastrointestinal bleeding, irrespective of comorbidity, except for exsanguinating haemorrhage. We randomly assigned hospitals (1:1) with a computer-generated randomisation sequence (random permuted block size of 6, without stratification or matching) to either a restrictive (transfusion when haemoglobin concentration fell below 80 g/L) or liberal (transfusion when haemoglobin concentration fell below 100 g/L) RBC transfusion policy. Neither patients nor investigators were masked to treatment allocation. Feasibility outcomes were recruitment rate, protocol adherence, haemoglobin concentration, RBC exposure, selection bias, and information to guide design and economic evaluation of the phase 3 trial. Main exploratory clinical outcomes were further bleeding and mortality at day 28. We did analyses on all enrolled patients for whom an outcome was available. This trial is registered, ISRCTN85757829 and NCT02105532. FINDINGS Between Sept 3, 2012, and March 1, 2013, we enrolled 936 patients across six hospitals (403 patients in three hospitals with a restrictive policy and 533 patients in three hospitals with a liberal policy). Recruitment rate was significantly higher for the liberal than for the restrictive policy (62% vs 55%; p=0·04). Despite some baseline imbalances, Rockall and Blatchford risk scores were identical between policies. Protocol adherence was 96% (SD 10) in the restrictive policy vs 83% (25) in the liberal policy (difference 14%; 95% CI 7-21; p=0·005). Mean last recorded haemoglobin concentration was 116 (SD 24) g/L for patients on the restrictive policy and 118 (20) g/L for those on the liberal policy (difference -2·0 [95% CI -12·0 to 7·0]; p=0·50). Fewer patients received RBCs on the restrictive policy than on the liberal policy (restrictive policy 133 [33%] vs liberal policy 247 [46%]; difference -12% [95% CI -35 to 11]; p=0·23), with fewer RBC units transfused (mean 1·2 [SD 2·1] vs 1·9 [2·8]; difference -0·7 [-1·6 to 0·3]; p=0·12), although these differences were not significant. We noted no significant difference in clinical outcomes. INTERPRETATION A cluster randomised design led to rapid recruitment, high protocol adherence, separation in degree of anaemia between groups, and non-significant reduction in RBC transfusion in the restrictive policy. A large cluster randomised trial to assess the effectiveness of transfusion strategies for acute upper gastrointestinal bleeding is both feasible and essential before clinical practice guidelines change to recommend restrictive transfusion for all patients with acute upper gastrointestinal bleeding. FUNDING NHS Blood and Transplant Research and Development.
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Affiliation(s)
- Vipul Jairath
- NHS Blood and Transplant, Oxford, UK; Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Brennan C Kahan
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Alasdair Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Caroline J Doré
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Ana Mora
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Martin W James
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Simon M Everett
- Department of Gastroenterology, St James's University Hospital, Leeds, UK
| | - Adam A Bailey
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Helen Dallal
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK
| | - John Greenaway
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK
| | - Ivan Le Jeune
- Department of Research and Education in Emergency Medicine, Acute Medicine and Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Melanie Darwent
- Department of Emergency Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Nicholas Church
- Department of Gastroenterology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ian Reckless
- Department of Acute General Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Renate Hodge
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Claire Dyer
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Sarah Meredith
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | | | | | - Richard F Logan
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Simon P Travis
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Timothy S Walsh
- Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Michael F Murphy
- NHS Blood and Transplant, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
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15
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Hoad CL, Palaniyappan N, Kaye P, Chernova Y, James MW, Costigan C, Austin A, Marciani L, Gowland PA, Guha IN, Francis ST, Aithal GP. A study of T₁ relaxation time as a measure of liver fibrosis and the influence of confounding histological factors. NMR Biomed 2015; 28:706-14. [PMID: 25908098 DOI: 10.1002/nbm.3299] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/04/2015] [Accepted: 03/11/2015] [Indexed: 05/25/2023]
Abstract
Liver biopsy is the standard test for the assessment of fibrosis in liver tissue of patients with chronic liver disease. Recent studies have used a non-invasive measure of T1 relaxation time to estimate the degree of fibrosis in a single slice of the liver. Here, we extend this work to measure T1 of the whole liver and investigate the effects of additional histological factors such as steatosis, inflammation and iron accumulation on the relationship between liver T1 and fibrosis. We prospectively enrolled patients who had previously undergone liver biopsy to have MR scans. A non-breath-holding, fast scanning protocol was used to acquire MR relaxation time data (T1 and T2*), and blood serum was used to determine the enhanced liver fibrosis (ELF) score. Areas under the receiver operator curves (AUROCs) for T1 to detect advanced fibrosis and cirrhosis were derived in a training cohort and then validated in a second cohort. Combining the cohorts, the influence of various histology factors on liver T1 relaxation time was investigated. The AUROCs (95% confidence interval (CI)) for detecting advanced fibrosis (F ≥ 3) and cirrhosis (F = 4) for the training cohort were 0.81 (0.65-0.96) and 0.92 (0.81-1.0) respectively (p < 0.01). Inflammation and iron accumulation were shown to significantly alter T1 in opposing directions in the absence of advanced fibrosis; inflammation increasing T1 and iron decreasing T1. A decision tree model was developed to allow the assessment of early liver disease based on relaxation times and ELF, and to screen for the need for biopsy. T1 relaxation time increases with advanced fibrosis in liver patients, but is also influenced by iron accumulation and inflammation. Together with ELF, relaxation time measures provide a marker to stratify patients with suspected liver disease for biopsy.
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Affiliation(s)
- Caroline L Hoad
- SPMIC, School of Physics and Astronomy, University of Nottingham, UK
- NIHR Nottingham Digestive Diseases Biomedical Research Unit at the Nottingham University Hospitals NHS Trust and University of Nottingham, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Digestive Diseases Biomedical Research Unit at the Nottingham University Hospitals NHS Trust and University of Nottingham, UK
| | - Philip Kaye
- NIHR Nottingham Digestive Diseases Biomedical Research Unit at the Nottingham University Hospitals NHS Trust and University of Nottingham, UK
- Department of Cellular Pathology, Nottingham University Hospitals NHS Trust, UK
| | - Yulia Chernova
- NIHR Nottingham Digestive Diseases Biomedical Research Unit at the Nottingham University Hospitals NHS Trust and University of Nottingham, UK
| | - Martin W James
- NIHR Nottingham Digestive Diseases Biomedical Research Unit at the Nottingham University Hospitals NHS Trust and University of Nottingham, UK
| | - Carolyn Costigan
- SPMIC, School of Physics and Astronomy, University of Nottingham, UK
| | | | - Luca Marciani
- NIHR Nottingham Digestive Diseases Biomedical Research Unit at the Nottingham University Hospitals NHS Trust and University of Nottingham, UK
| | - Penny A Gowland
- SPMIC, School of Physics and Astronomy, University of Nottingham, UK
| | - Indra N Guha
- NIHR Nottingham Digestive Diseases Biomedical Research Unit at the Nottingham University Hospitals NHS Trust and University of Nottingham, UK
| | - Susan T Francis
- SPMIC, School of Physics and Astronomy, University of Nottingham, UK
| | - Guruprasad P Aithal
- NIHR Nottingham Digestive Diseases Biomedical Research Unit at the Nottingham University Hospitals NHS Trust and University of Nottingham, UK
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16
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Harman DJ, Ryder SD, James MW, Jelpke M, Ottey DS, Wilkes EA, Card TR, Aithal GP, Guha IN. Direct targeting of risk factors significantly increases the detection of liver cirrhosis in primary care: a cross-sectional diagnostic study utilising transient elastography. BMJ Open 2015; 5:e007516. [PMID: 25941185 PMCID: PMC4420978 DOI: 10.1136/bmjopen-2014-007516] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To assess the feasibility of a novel diagnostic algorithm targeting patients with risk factors for chronic liver disease in a community setting. DESIGN Prospective cross-sectional study. SETTING Two primary care practices (adult patient population 10,479) in Nottingham, UK. PARTICIPANTS Adult patients (aged 18 years or over) fulfilling one or more selected risk factors for developing chronic liver disease: (1) hazardous alcohol use, (2) type 2 diabetes or (3) persistently elevated alanine aminotransferase (ALT) liver function enzyme with negative serology. INTERVENTIONS A serial biomarker algorithm, using a simple blood-based marker (aspartate aminotransferase:ALT ratio for hazardous alcohol users, BARD score for other risk groups) and subsequently liver stiffness measurement using transient elastography (TE). MAIN OUTCOME MEASURES Diagnosis of clinically significant liver disease (defined as liver stiffness ≥8 kPa); definitive diagnosis of liver cirrhosis. RESULTS We identified 920 patients with the defined risk factors of whom 504 patients agreed to undergo investigation. A normal blood biomarker was found in 62 patients (12.3%) who required no further investigation. Subsequently, 378 patients agreed to undergo TE, of whom 98 (26.8% of valid scans) had elevated liver stiffness. Importantly, 71/98 (72.4%) patients with elevated liver stiffness had normal liver enzymes and would be missed by traditional investigation algorithms. We identified 11 new patients with definite cirrhosis, representing a 140% increase in the number of diagnosed cases in this population. CONCLUSIONS A non-invasive liver investigation algorithm based in a community setting is feasible to implement. Targeting risk factors using a non-invasive biomarker approach identified a substantial number of patients with previously undetected cirrhosis. TRIAL REGISTRATION NUMBER The diagnostic algorithm utilised for this study can be found on clinicaltrials.gov (NCT02037867), and is part of a continuing longitudinal cohort study.
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Affiliation(s)
- David J Harman
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Stephen D Ryder
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Martin W James
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Matthew Jelpke
- NHS Rushcliffe Clinical Commissioning Group, Nottingham, UK
| | | | - Emilie A Wilkes
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Timothy R Card
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Guruprasad P Aithal
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Indra Neil Guha
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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Campbell HE, Stokes EA, Bargo D, Logan RF, Mora A, Hodge R, Gray A, James MW, Stanley AJ, Everett SM, Bailey AA, Dallal H, Greenaway J, Dyer C, Llewelyn C, Walsh TS, Travis SPL, Murphy MF, Jairath V. Costs and quality of life associated with acute upper gastrointestinal bleeding in the UK: cohort analysis of patients in a cluster randomised trial. BMJ Open 2015; 5:e007230. [PMID: 25926146 PMCID: PMC4420945 DOI: 10.1136/bmjopen-2014-007230] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Data on costs associated with acute upper gastrointestinal bleeding (AUGIB) are scarce. We provide estimates of UK healthcare costs, indirect costs and health-related quality of life (HRQoL) for patients presenting to hospital with AUGIB. SETTING Six UK university hospitals with >20 AUGIB admissions per month, >400 adult beds, 24 h endoscopy, and on-site access to intensive care and surgery. PARTICIPANTS 936 patients aged ≥18 years, admitted with AUGIB, and enrolled between August 2012 and March 2013 in the TRIGGER trial of AUGIB comparing restrictive versus liberal red blood cell (RBC) transfusion thresholds. PRIMARY AND SECONDARY OUTCOME MEASURES Healthcare resource use during hospitalisation and postdischarge up to 28 days, unpaid informal care, time away from paid employment and HRQoL using the EuroQol EQ-5D at 28 days were measured prospectively. National unit costs were used to value resource use. Initial in-hospital treatment costs were upscaled to a UK level. RESULTS Mean initial in-hospital costs were £2458 (SE=£216) per patient. Inpatient bed days, endoscopy and RBC transfusions were key cost drivers. Postdischarge healthcare costs were £391 (£44) per patient. One-third of patients received unpaid informal care and the quarter in paid employment required time away from work. Mean HRQoL for survivors was 0.74. Annual initial inhospital treatment cost for all AUGIB cases in the UK was estimated to be £155.5 million, with exploratory analyses of the incremental costs of treating hospitalised patients developing AUGIB generating figures of between £143 million and £168 million. CONCLUSIONS AUGIB is a large burden for UK hospitals with inpatient stay, endoscopy and RBC transfusions as the main cost drivers. It is anticipated that this work will enable quantification of the impact of cost reduction strategies in AUGIB and will inform economic analyses of novel or existing interventions for AUGIB. TRIAL REGISTRATION NUMBER ISRCTN85757829 and NCT02105532.
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Affiliation(s)
- H E Campbell
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - E A Stokes
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - D Bargo
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - R F Logan
- Nottingham Digestive Diseases NIHR Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - A Mora
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - R Hodge
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - A Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M W James
- Nottingham Digestive Diseases NIHR Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - A J Stanley
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - S M Everett
- Department of Gastroenterology, St James's University Hospital, Leeds, UK
| | - A A Bailey
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - H Dallal
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK
| | - J Greenaway
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK
| | - C Dyer
- Clinical Trials Unit, NHS Blood and Transplant, Oxford, UK
| | - C Llewelyn
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - T S Walsh
- Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - S P L Travis
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M F Murphy
- Clinical Trials Unit, NHS Blood and Transplant, Oxford, UK National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals and University of Oxford, Oxford, UK
| | - V Jairath
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK Clinical Trials Unit, NHS Blood and Transplant, Oxford, UK
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18
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Dolman GE, Nieboer D, Steyerberg EW, Harris S, Ferguson A, Zaitoun AM, Ryder SD, James MW, Aithal GP, Guha IN. The performance of transient elastography compared to clinical acumen and routine tests - what is the incremental diagnostic value? Liver Int 2013; 33:172-9. [PMID: 23136951 DOI: 10.1111/liv.12017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 09/17/2012] [Indexed: 02/13/2023]
Abstract
BACKGROUND/AIMS There is substantial evidence suggesting transient elastography (TE) is a useful tool in assessing liver fibrosis. We aimed to determine whether TE has incremental diagnostic value over clinical acumen and routinely available tests. METHODS We performed a retrospective study of 130 patients to assess the ability of hepatologists to predict severity of fibrosis using clinical acumen; clinical acumen with routine tests; and elastography in patients with chronic liver disease. The incremental diagnostic benefit was assessed using the area under the ROC curve (AUC) and the Net Reclassification Index (NRI). RESULTS Using universally available tests, including clinical acumen, the AUCs for detection of cirrhosis ranged from 0.70 to 0.80 for the four hepatologists. Elastography led to statistically non-significant improvements in AUC statistics (range 0.83-0.89; P > 0.01). The detection of significant fibrosis using clinical acumen and routine tests was less accurate, with AUCs of 0.52-0.59. Elastography had incremental diagnostic value (AUC performance range 0.76-0.82; P < 0.01). The NRI indicated that 39-58% were correctly reclassified using elastography, especially with respect to sensitivity. CONCLUSIONS Our study suggests that the diagnostic value of clinical acumen and routine tests is acceptable for detection of cirrhosis, but not significant fibrosis. Elastography detects significant fibrosis or cirrhosis with acceptable accuracy and offered incremental diagnostic value in detecting significant fibrosis, but not cirrhosis. These findings have implications for determining the diagnostic value of tests over and above routine clinical assessment, which will aid incorporation of novel tests into clinical algorithms.
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Affiliation(s)
- Grace E Dolman
- NIHR Biomedical Research Unit (Gastrointestinal and Liver), Nottingham University Hospitals and University of Nottingham, Nottingham, UK
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19
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McCorry RB, Palaniyappan N, Chivinge A, Kaye P, James MW, Aithal GP. Development and evaluation of a nurse-led transient elastography service for the staging of hepatic fibrosis in patients with suspected chronic liver disease. QJM 2012; 105:749-54. [PMID: 22408151 DOI: 10.1093/qjmed/hcs043] [Citation(s) in RCA: 15] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND AIMS Establishing the presence of fibrosis and cirrhosis is an essential step in the management of patients with chronic liver diseases (CLD). Liver stiffness measurement (LSM) based on transient elastography (TE) correlates well with the stages of liver fibrosis and has been developed as a non-invasive alternative to liver biopsy. The studies performed to date have used physician operators. With the potential use of TE for screening of community-based populations for liver disease, we aimed to evaluate the performance of nurse operators. DESIGN Retrospective analysis. METHODS We reviewed the reliability and accuracy of LSMs performed by the nurse-led TE service at Queen's Medical Centre, Nottingham between May 2009 and January 2011. Consecutive patients with suspected CLD who underwent LSM were included. RESULTS Over the study period 585 LSMs were performed. Analysis was performed on the 208 patients where LSM could be compared with liver biopsy findings. Of these 11 (5.3%) had unreliable LSM results (less than 10 valid shots or success rate <60%). There were no LSM failures. Inadequate liver biopsy specimen led to exclusion in 26 (12.5%) patients. For the detection of significant fibrosis (Ishak stage >2), a sensitivity of 0.78 and specificity of 0.81 was obtained, with a cut-off value of 8 kPa. Using a cut-off value of 13 kPa for detection of cirrhosis, a sensitivity and specificity of 0.8 and 0.92 was obtained. CONCLUSION We have demonstrated that a nurse-led TE service can produce a low level of unreliable results and LSM failures, with comparable sensitivity and specificity for detecting significant fibrosis and cirrhosis to those reported in the literature. The demands on the use of TE could potentially be eased through the introduction of nurse-led service delivery.
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Affiliation(s)
- R B McCorry
- Department of Hepatology, National Institute of Health Research: Biomedical Research Unit, Nottingham University Hospital NHS Trust, Nottingham NG7 2UH, UK.
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Abstract
BACKGROUND Iron deficiency anaemia (IDA) occurs in 2-5% of adult men and postmenopausal women in the developed world and is a common cause of referral to gastroenterologists. Gastrointestinal (GI) blood loss from colonic cancer or gastric cancer, and malabsorption in coeliac disease are the most important causes that need to be sought. DEFINING IRON DEFICIENCY ANAEMIA: The lower limit of the normal range for the laboratory performing the test should be used to define anaemia (B). Any level of anaemia should be investigated in the presence of iron deficiency (B). The lower the haemoglobin the more likely there is to be serious underlying pathology and the more urgent is the need for investigation (B). Red cell indices provide a sensitive indication of iron deficiency in the absence of chronic disease or haemoglobinopathy (A). Haemoglobin electrophoresis is recommended when microcytosis and hypochromia are present in patients of appropriate ethnic background to prevent unnecessary GI investigation (C). Serum ferritin is the most powerful test for iron deficiency (A). INVESTIGATIONS Upper and lower GI investigations should be considered in all postmenopausal female and all male patients where IDA has been confirmed unless there is a history of significant overt non-GI blood loss (A). All patients should be screened for coeliac disease (B). If oesophagogastroduodenoscopy (OGD) is performed as the initial GI investigation, only the presence of advanced gastric cancer or coeliac disease should deter lower GI investigation (B). In patients aged >50 or with marked anaemia or a significant family history of colorectal carcinoma, lower GI investigation should still be considered even if coeliac disease is found (B). Colonoscopy has advantages over CT colography for investigation of the lower GI tract in IDA, but either is acceptable (B). Either is preferable to barium enema, which is useful if they are not available. Further direct visualisation of the small bowel is not necessary unless there are symptoms suggestive of small bowel disease, or if the haemoglobin cannot be restored or maintained with iron therapy (B). In patients with recurrent IDA and normal OGD and colonoscopy results, Helicobacter pylori should be eradicated if present. (C). Faecal occult blood testing is of no benefit in the investigation of IDA (B). All premenopausal women with IDA should be screened for coeliac disease, but other upper and lower GI investigation should be reserved for those aged 50 years or older, those with symptoms suggesting gastrointestinal disease, and those with a strong family history of colorectal cancer (B). Upper and lower GI investigation of IDA in post-gastrectomy patients is recommended in those over 50 years of age (B). In patients with iron deficiency without anaemia, endoscopic investigation rarely detects malignancy. Such investigation should be considered in patients aged >50 after discussing the risk and potential benefit with them (C). Only postmenopausal women and men aged >50 years should have GI investigation of iron deficiency without anaemia (C). Rectal examination is seldom contributory, and, in the absence of symptoms such as rectal bleeding and tenesmus, may be postponed until colonoscopy. Urine testing for blood is important in the examination of patients with IDA (B). MANAGEMENT All patients should have iron supplementation both to correct anaemia and replenish body stores (B). Parenteral iron can be used when oral preparations are not tolerated (C). Blood transfusions should be reserved for patients with or at risk of cardiovascular instability due to the degree of their anaemia (C).
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21
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Le Jeune IR, Gordon AL, Farrugia D, Manwani R, Guha IN, James MW. Safe discharge of patients with low-risk upper gastrointestinal bleeding (UGIB): can the use of Glasgow-Blatchford Bleeding Score be extended? Acute Med 2011; 10:176-181. [PMID: 22111089] [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: 05/31/2023]
Abstract
INTRODUCTION Risk stratification of patients with suspected upper gastrointestinal bleeding (UGIB) using either Glasgow-Blatchford Bleeding Score (GBS) or preendoscopy Rockall score to facilitate early safe discharge (GBS=0, pre-Rockall=0) has been reported. This observational study compared score utility and considered the impact of extending the range of GBS or pre-Rockall scores permitting safe discharge. METHODS Consecutive adult patients presenting to acute medical admissions or the emergency department from September 2008-March 2009 with suspected UGIB had clinical history, vital signs, laboratory and endoscopy results prospectively recorded using electronic databases. GBS, pre-Rockall scores and a composite endpoint (blood transfusion, endoscopic therapy, interventional radiology, surgery or 30-day mortality) were calculated. RESULTS 388 patients with suspected UGIB were identified of which 92.3% were admitted (median (range) GBS=5 (0-19) and pre-Rockall=2 (0-11)) and 7.7% discharged (GBS=0 (0-4) and pre-Rockall=0 (0-4)). 186 (47.9%) underwent in-patient endoscopy. 151 (38.9%) were found to have the composite endpoint with 77.5% having transfusion, 45.7% endoscopic treatment and an 8.0% mortality within 30 days. AUROC (95% CI) for 30-day composite endpoint was 0.92 (0.89-0.94) using GBS and 0.75 (0.70-0.80) using pre-Rockall scores. Analysis using different GBS thresholds demonstrated that GBS=0, GBS ≤1 and GBS≤2 had superior utility in identifying freedom from an adverse clinical outcome at 30-days than pre-Rockall score 0. CONCLUSIONS GBS is superior to pre-Rockall score in identifying patients with suspected UGIB who have a low likelihood of an adverse clinical outcome and can be considered for early discharge. Diagnostic performance at different thresholds suggests that patients with GBS≤2 could be considered for early discharge, doubling the number of eligible patients (15.2 to 32.5%). This has important patient safety and resource implications.
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Affiliation(s)
- I R Le Jeune
- Division of Acute Medicine, Nottingham University Hospital, UK.
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22
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Abstract
Postoperative biliary strictures are the most common cause of benign biliary stricture in Western countries, secondary to either operative injury or bile duct anastomotic stricture following orthotopic liver transplantation (OLT). Surgery or endoscopic interventions are the mainstay of treatment for benign biliary strictures. We aim to report the outcome of 2 patients with refractory anastomotic biliary stricture post-OLT, who had successful temporary placement of a prototype removable covered self-expandable metal stent (RCSEMS). These 2 patients (both men, aged 44 and 53 years) were given temporary placement of a prototype RCSEMS (8.5 Fr gauge delivery system, 8 mm × 40 mm stent dimensions) in the common bile duct across the biliary stricture. There was no morbidity associated with stent placement and removal in these 2 cases. Clinical parameters improved after the RCSEMS placement. Long-term biliary patency was achieved in both the patients. No further biliary intervention was required within 14 and 18 mo follow-up after stent removal.
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24
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James MW, Taylor N, Aithal GP. Dyspnoea in a patient with cirrhosis. Gut 2009; 58:156. [PMID: 19091847 DOI: 10.1136/gut.2008.170795] [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: 12/08/2022]
Affiliation(s)
- M W James
- Nottingham Digestive Diseases Biomedical Research Unit, Queen's Medical Centre Nottingham.
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Abstract
OBJECTIVES Iron-deficiency anaemia (IDA) is common and may be caused by blood loss from gastrointestinal tumours. The aim of this study was to define risk factors for gastrointestinal malignancy in patients with IDA. METHODS Patients with suspected IDA referred for gastrointestinal investigations were prospectively identified from two neighbouring UK hospitals (serving a population of 550,000 patients) between 1 January 1998 and 31 December 1999. Final diagnoses were determined after 2 years, and those patients with and without gastrointestinal cancer as a cause for their IDA were compared. Data collected included sex, age, haemoglobin, serum ferritin, mean cell volume and drug history. RESULTS A total of 695 patients (236 men, mean age 68.5 years; 459 women, mean age 66.2 years) with IDA were investigated. Malignancy was diagnosed in 91/695 (13.1%) and gastrointestinal malignancy in 78/91 (11.2%). The most frequently diagnosed cancers were colonic (n = 44, 6.3%), gastric (n = 25, 3.6%) and renal tract (n = 7, 1%). The adjusted odds ratio (+/-95% confidence interval) for gastrointestinal cancer as a cause of IDA was significantly higher for male sex [2.96 (1.80, 4.87)], age over 50 years [7.04 (1.69, 29.32)] and haemoglobin level at presentation (< or =9.0 g/dl) [2.25 (1.29, 3.90)]. There was no significant difference in gastrointestinal malignancy in those taking aspirin (12/111, 10.8%), non-aspirin non-steroidal anti-inflammatory drugs (5/84, 6.0%) or warfarin (4/31, 12.9%) compared with those not taking these drugs (57/470, 12.1%). No cause for IDA was found in 53.7%. CONCLUSIONS Cancer was diagnosed in 13.1% and gastrointestinal cancer in 11.2% of patients with IDA. Significant risk factors for gastrointestinal malignancy in IDA patients are male sex, age over 50 years and haemoglobin at presentation < or =9.0 g/dl. IDA should not be attributed to aspirin, non-steroidal anti-inflammatory drugs or warfarin use.
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Affiliation(s)
- Martin W James
- Wolfson Digestive Diseases Centre, University Hospital, Nottingham, UK.
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26
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Kerry JE, Marshall C, Griffiths PA, James MW, Scott BB. Comparison between Tc-HMPAO labelled white cells and Tc LeukoScan in the investigation of inflammatory bowel disease. Nucl Med Commun 2005; 26:245-51. [PMID: 15722905 DOI: 10.1097/00006231-200503000-00009] [Citation(s) in RCA: 11] [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] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES (99m)Tc-HMPAO labelled leukocyte imaging (white cell scan) is used in the investigation and assessment of patients with inflammatory bowel disease (IBD), while (99m)Tc LeukoScan has been used to demonstrate the presence of orthopaedic infections and appendicitis. The single-injection technique used for the administration of LeukoScan removes the need for handling blood and the complex separation and labelling techniques that are required for white cell imaging. This study set out to investigate whether LeukoScan could be used to image IBD. METHODS Twenty-two patients under investigation for suspected IBD agreed to undergo LeukoScan imaging within 7 days of their routine planar white cell scan. Following injection of 650 MBq (99m)Tc LeukoScan planar images were acquired at 1, 2 and 4 h and single photon emission computed tomography (SPECT) images at 4 h post-injection. RESULTS When both sets of images were compared to the clinical diagnosis, the sensitivity and specificity were 0.88 and 0.83 for white cell imaging and 0.88 and 0.50 for LeukoScan SPECT at 4 h. The figures for the specificity and sensitivity of the LeukoScan 2 h and 4 h planar images were 0.44 and 1.00, and 0.75 and 0.50, respectively. When the LeukoScan and white cell images were compared, the 4 h LeukoScan SPECT images showed additional areas of uptake in 10 patients. CONCLUSIONS The study demonstrates that LeukoScan locates IBD. However, the sensitivity and specificity preclude its use for the routine detection of this disease. Comparisons with white cell scan images show that LeukoScan is taken up slowly in IBD and also appears in the normal bowel by 4 h.
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Affiliation(s)
- Joanne E Kerry
- Department of Medical Physics, Lincoln County Hospital, Greetwell Road, Lincoln LN2 5QY, UK.
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27
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Abstract
Aspirin is widely prescribed and confers considerable benefit to patients by reducing cardiovascular and cerebrovascular morbidity and mortality. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective analgesics, antipyretics and reduce the inflammatory component in conditions such as rheumatoid arthritis. However, both agents are associated with an increased risk of gastrointestinal symptoms and the potentially serious consequences of gastroduodenal ulceration, bleeding and perforation. The introduction of highly selective cyclo-oxygenase (COX)-2 inhibitors or the coprescription gastroprotective agents with nonselective NSAIDs have offered strategies to reduce the incidence of such events. This review article analyzes the quantitative techniques that can be employed by clinical pharmacologists and the clinical studies performed to assess NSAID damage in the gastrointestinal tract.
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Affiliation(s)
- Martin W James
- Wolfson Digestive Diseases Centre, University Hospital Nottingham, Nottingham NG7 2UH.
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28
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Abstract
The outcome of infection with hepatitis C virus (HCV) varies greatly. The virus associates with serum lipoproteins, including those containing apolipoprotein E (apoE) and apolipoprotein B (apoB), and may enter cells via the low-density lipoprotein receptor (LDLR). ApoE genotypes can affect the extent of damage in diseases caused by 2 other viruses--herpes simplex virus type 1 (HSV1; in Alzheimer's disease and herpes labialis) and human immunodeficiency virus (HIV). We therefore investigated whether specific apoE and apoB alleles were associated with different outcomes of HCV infection. A total of 156 anti-HCV-positive patients and 104 non-HCV-infected patients were studied. Liver biopsy specimens from patients with chronic HCV infection (n = 111) were assessed for disease severity by the Knodell system. ApoE and apoB genotypes were determined by standard polymerase chain reaction (PCR) methods. There was no significant difference among the apoE genotypes of HCV-infected subjects compared with previously published population data, or between HCV-RNA positive or negative patients. However, chronically HCV-infected subjects with mild liver disease (n = 65) had a significantly higher apoE-epsilon 4 allele frequency (20.0%) than those (n = 46) with severe disease (6.5%). ApoB alleles alone or in combination with apoE were not associated with mild or severe disease. The overall apoE allele frequencies of patients with liver disease not caused by HCV were similar to those of the total HCV group and in contrast to the HCV patients, the apoE allele frequencies were similar in those patients with no or mild fibrosis as compared with those with bridging fibrosis or cirrhosis. In conclusion, carriage of an apoE-epsilon 4 allele may be protective against liver damage caused by HCV, but not against damage due to various nonviral causes. This is yet another case in which apoE may determine the severity of a viral disease.
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Affiliation(s)
- Matthew A Wozniak
- Molecular Neurobiology Laboratory, Department of Optometry & Neuroscience, University of Manchester Institute of Science and Technology, Manchester, UK
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Abstract
The advent of the endomysial antibody test has allowed the true association between coeliac disease and at least 12 other disorders to be established. There is evidence suggesting that coeliac disease is a cause of these disorders; a mechanism for this is proposed.
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Affiliation(s)
- M W James
- Department of Gastroenterology, Lincoln County Hospital, Lincoln LN2 5QY, UK
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James MW, Beckingham IJ. Recent developments in hepatology. Practitioner 2001; 245:652, 655-8. [PMID: 11524936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Affiliation(s)
- M W James
- Department of Gastroenterology, University Hospital, Queen's Medical Centre, Nottingham
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James MW, Ryder S. Casebook: jaundice. Practitioner 2001; 245:664-7. [PMID: 11524938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- M W James
- Hepatologist, Queen's Medical Centre, Nottingham
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Abstract
This review determines the significance, usefulness, and application of the endomysial antibody test for coeliac disease in clinical practice.
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Affiliation(s)
- M W James
- Department of Gastroenterology, County Hospital, Lincoln, UK
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Crews BC, James MW, Beth AH, Gettins P, Cunningham LW. In support of the trap hypothesis. Chymotrypsin is not rigidly held in its complex with human alpha 2-macroglobulin. Biochemistry 1987; 26:5963-7. [PMID: 2446656 DOI: 10.1021/bi00393a003] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Complexes (2:1) of chymotrypsin with human alpha 2-macroglobulin have been prepared in the presence of 200 mM methylamine such that 90% of the chymotrypsin remains noncovalently bound to the alpha 2-macroglobulin. Reaction of this complex with the active-site-directed spin-labeling reagent 4-[(ethoxyfluorophosphinyl)oxy]-2,2,6,6-tetramethylpiperidinyl+ ++-1-oxy results in nitroxide labeling of the active-site serine residue of the complexed chymotrypsin. Electron spin resonance (ESR) spectra of this complex were recorded at 275 K in buffer and at 263 K in 50% glycerol. At 263 K in 50% glycerol the spectrum is that expected for a rigid glass, whereas at room temperature the ESR spectrum shows that the chymotrypsin is only slightly immobilized compared with free spin-labeled chymotrypsin. These findings are discussed in relation to possible models of inhibition of protease activity by alpha 2-macroglobulin. It is concluded that the trap mechanism of Barrett and Starkey [Barrett, A. J., & Starkey, P. M. (1973) Biochem. J. 133, 709-724] is the only model currently considered that can account for the present findings.
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Affiliation(s)
- B C Crews
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, Tennessee 37232
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