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Hanlon P, Welsh SA, Evans NR. Constructing a quality frailty index: you get out what you put in. Age Ageing 2024; 53:afad248. [PMID: 38266125 DOI: 10.1093/ageing/afad248] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Indexed: 01/26/2024] Open
Affiliation(s)
- Peter Hanlon
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Silje A Welsh
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Maes L, Versweyveld L, Evans NR, McCabe JJ, Kelly P, Van Laere K, Lemmens R. Novel Targets for Molecular Imaging of Inflammatory Processes of Carotid Atherosclerosis: A Systematic Review. Semin Nucl Med 2023:S0001-2998(23)00085-5. [PMID: 37996309 DOI: 10.1053/j.semnuclmed.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023]
Abstract
Computed tomography angiography (CTA), magnetic resonance angiography (MRA) and 18F-FDG-PET have proven clinical value when evaluating patients with carotid atherosclerosis. In this systematic review, we will focus on the role of novel molecular imaging tracers in that assessment and their potential strengths to stratify stroke risk. We systematically searched PubMed, Embase, the Web of Science Core Collection, and Cochrane Library for articles reporting on molecular imaging to noninvasively detect or characterize inflammation in carotid atherosclerosis. As our focus was on nonclassical novel targets, we omitted reports solely on 18F-FDG and 18F-NaF. We summarized and mapped the selected studies to provide an overview of the current clinical development in molecular imaging in relation to risk factors, imaging and histological findings, diagnostic and prognostic performance. We identified 20 articles in which the utilized tracers to visualize carotid wall inflammation were somatostatin subtype-2- (SST2-) (n = 5), CXC-motif chemokine receptor 4- (CXCR4-) (n = 3), translocator protein- (TSPO-) (n = 2) and aVβ3 integrin-ligands (n = 2) and choline-tracers (n = 2). Tracer uptake correlated with traditional cardiovascular risk factors, that is, age, gender, diabetes, hypercholesterolemia, and hypertension as well as prior cardiovascular disease. We identified discrepancies between tracer uptake and grade of stenosis, plaque calcification, and 18F-FDG uptake, suggesting the importance of alternative characterization of atherosclerosis beyond classical neuroimaging features. Immunohistochemical analysis linked tracer uptake to markers of macrophage infiltration and neovascularization. Symptomatic carotid arteries showed higher uptake compared to asymptomatic (including contralateral, nonculprit) arteries. Some studies demonstrated a potential role of these novel molecular imaging as a specific intermediary (bio)marker for outcome. Several novel tracers show promise for identification of high-risk plaque inflammation. Based on the current evidence we cautiously propose the SST2-ligands and the choline radiotracers as viable candidates for larger prospective longitudinal outcome studies to evaluate their predictive use in clinical practice.
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Affiliation(s)
- Louise Maes
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium.
| | - Louis Versweyveld
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium
| | - Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - John J McCabe
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland; School of Medicine, University College Dublin (UCD), Dublin, Ireland; Department of Geriatric Medicine, Mater Misericordiae University Hospital Dublin, Dublin, Ireland
| | - Peter Kelly
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland; School of Medicine, University College Dublin (UCD), Dublin, Ireland; Mater Misericordiae University Hospital Dublin, Stroke Service, Dublin, Ireland
| | - Koen Van Laere
- Division of Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Imaging and Pathology, KULeuven - University of Leuven - Nuclear Medicine and Molecular Imaging, Leuven, Belgium
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium
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Fraig H, Gibbs DMR, Lloyd-Jones G, Evans NR, Barham GS, Dabke HV. Early experience of a local pathway on the waiting time for MRI in patients presenting to a UK district general hospital with suspected cauda equina syndrome. Br J Neurosurg 2023; 37:1094-1100. [PMID: 35232306 DOI: 10.1080/02688697.2022.2039377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/02/2022] [Indexed: 11/02/2022]
Abstract
AIM This study evaluated the impact of the Salisbury Protocol for Assessment of Cauda Equina Syndrome (SPACES) on the waiting time for MRI in patients presenting with suspected Cauda Equina Syndrome (sCES) within a UK district general hospital. PATIENTS AND METHODS All consecutive patients undergoing an MRI scan in our hospital, for sCES, over a 12 month period, prior to and following the introduction of SPACES, were identified. Patient's gender, age, MRI diagnosis, time from MRI request to imaging and outcome were recorded. RESULTS In the year prior to the introduction of SPACES, 66 patients underwent MRI for sCES, out of which 10.6% had cauda equina compression (CEC), 63.5% had other spinal pathology and 25% had a normal scan. In the year after introduction of SPACES, 160 patients underwent MRI for sCES out of which 6.2% had CEC, 70.7% had other spinal pathology and 23% had a normal scan. Despite the referrals for sCES increasing by more than 2-fold following the introduction of SPACES, the median time from MRI request to scan decreased from 9.1 to 4.2 hours (p = 0.106, Mann-Whitney-U) and the number of patients transferred to the regional hub hospital decreased from 7 to 3. CONCLUSION Implementation of SPACES for patients with sCES resulted in a substantial reduction in waiting time for MRI and decreased the number of transfers to the regional hub hospital. Based on our early experience, we encourage other centres within the UK to introduce such a pathway locally, to improve the management of patients with sCES.
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Affiliation(s)
- H Fraig
- Specialty Registrar Trauma & Orthopaedic Surgery, Salisbury District Hospital, Salisbury, UK
| | - D M R Gibbs
- Trust Grade Trauma & Orthopaedic Surgeon, Salisbury District Hospital, Salisbury, UK
| | - G Lloyd-Jones
- Consultant Radiologist, Salisbury District Hospital, Salisbury, UK
| | - N R Evans
- Consultant Spinal and Trauma Surgeon, Salisbury District Hospital, Salisbury, UK
| | - G S Barham
- Consultant Spinal and Trauma Surgeon, Salisbury District Hospital, Salisbury, UK
| | - H V Dabke
- Consultant Spinal and Trauma Surgeon, Salisbury District Hospital, Salisbury, UK
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4
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Stubbs DJ, Davies BM, Dixon-Woods M, Bashford TH, Braude P, Bulters D, Camp S, Carr G, Coles JP, Dhesi J, Dinsmore J, Edlmann E, Evans NR, Figaji A, Foster E, Lecky F, Kolias A, Joannides A, Moppett I, Nathanson M, Newcombe V, Owen N, Peterman L, Proffitt A, Skiterall C, Whitfield P, Wilson SR, Zolnourian A, Amarouche M, Ansari A, Borg N, Brennan PM, Brown C, Corbett C, Dammers R, Das T, Feilding E, Galea M, Gillespie C, Glancz L, Gooding F, Grange R, Gray N, Hartley P, Hassan T, Holl D, Jones J, Knight R, Luoma V, Mee H, Minett T, Novak S, Peck G, Ralhan S, Ramshaw J, Richardson D, Sadek AR, Sheehan K, Sheppard F, Shipway D, Singh N, Smith M, Sturley R, Swart M, Thomas W, Uprichard J, Yeardley V, Menon DK, Hutchinson PJ. Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma. Wellcome Open Res 2023; 8:390. [PMID: 38434734 PMCID: PMC10905132 DOI: 10.12688/wellcomeopenres.18478.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 03/05/2024] Open
Abstract
Introduction: A common neurosurgical condition, chronic subdural haematoma (cSDH) typically affects older people with other underlying health conditions. The care of this potentially vulnerable cohort is often, however, fragmented and suboptimal. In other complex conditions, multidisciplinary guidelines have transformed patient experience and outcomes, but no such framework exists for cSDH. This paper outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH. Methods: The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement. Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework. The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents. Conclusions: We present a protocol for the development of a multidisciplinary guideline to inform the care of patients with a cSDH, developed by cross-disciplinary working groups and arrived at through a consensus-building process, including a modified online Delphi.
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Affiliation(s)
- Daniel J Stubbs
- Division of Perioperative, Acute, and Critical care, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
- Healthcare Design Group, Department of Engineering, University of Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Department of Clinical Neurosurgery, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Mary Dixon-Woods
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Thomas H Bashford
- Division of Perioperative, Acute, and Critical care, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
- Healthcare Design Group, Department of Engineering, University of Cambridge, Cambridge, UK
| | - Philip Braude
- Department of Medicine for Older People, North Bristol NHS Trust, Bristol, UK
| | - Diedrik Bulters
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Sophie Camp
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Jonathan P Coles
- Division of Perioperative, Acute, and Critical care, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Jugdeep Dhesi
- Department of Geriatric Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Judith Dinsmore
- Department of Anaesthesia, St George's University NHS Trust, London, UK
| | - Ellie Edlmann
- Department of Neurosurgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Anthony Figaji
- Department of Neurosurgery, University of Cape Town, Cape Town, South Africa
| | - Emily Foster
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Fiona Lecky
- Department of Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Angelos Kolias
- Department of Clinical Neurosurgery, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Alexis Joannides
- Department of Clinical Neurosurgery, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Iain Moppett
- Department of Anaesthesia and Perioperative Medicine, University of Nottingham, Nottingham, UK
| | - Mike Nathanson
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Virginia Newcombe
- Division of Perioperative, Acute, and Critical care, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Nicola Owen
- Department of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Amy Proffitt
- Department of Palliative Medicine, Barts and The London NHS Trust, London, UK
| | - Charlotte Skiterall
- Pharmacy Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter Whitfield
- Department of Neurosurgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Sally R Wilson
- Department of Anaesthesia and Critical Care, National Hospital for Neurology and Neurosurgery, London, UK
| | - Ardalan Zolnourian
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | | | - Akbar Ansari
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Nick Borg
- Department of Neurosurgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Paul M Brennan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Charlotte Brown
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Christopher Corbett
- ACP in Emergency Medicine, Norfolk & Norwich University Hospital, Norwich, UK
| | - Ruben Dammers
- Neurosurgeon, Erasmus MC Stroke Center, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tilak Das
- Consultant Neuroradiologist, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emily Feilding
- Consultant Geriatrician (Major Trauma), Salford Royal Hospital, Salford, UK
| | - Marilise Galea
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Conor Gillespie
- Department of Clinical Neurosurgery, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Laurence Glancz
- Department of Neurosurgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Felix Gooding
- Department of Emergency Medicine, St Thomas' Hospital, London, UK
| | - Robert Grange
- Department of Medicine for Older People, North Bristol NHS Trust, Bristol, UK
| | - Natalie Gray
- Department of Physiotherapy, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter Hartley
- Department of Physiotherapy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Taj Hassan
- Department of Emergency Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Dana Holl
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Julia Jones
- Department of Neurosurgery, St George's Hospital, London, UK
| | | | - Val Luoma
- Department of Anaesthesia and Critical Care, National Hospital for Neurology and Neurosurgery, London, UK
| | - Harry Mee
- Department of Rehabilitation Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thais Minett
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen Novak
- Department of Rehabilitation Medicine, North Bristol NHS Trust, Bristol, UK
| | - George Peck
- Department of Geriatric Medicine, Imperial College London, London, UK
| | - Shvaita Ralhan
- Department of Geriatric Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jennifer Ramshaw
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Davina Richardson
- Department of Neurosciences, Imperial College Healthcare NHS Trust, London, UK
| | - Ahmed-Ramadan Sadek
- Department of Neurosurgery, Barking Havering Redbridge University Trust, Romford, UK
| | - Katie Sheehan
- Rehabilitation and Health Services Research, Kings College, London, UK
| | - Francoise Sheppard
- Department of Emergency Medicine, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - David Shipway
- Department of Medicine for Older People, North Bristol NHS Trust, Bristol, UK
| | - Navneet Singh
- Department of Neurosurgery, St George's Hospital, London, UK
| | - Martin Smith
- Department of Emergency Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Rhonda Sturley
- Department of Geriatric Medicine, St George's, University of London, London, UK
| | - Michael Swart
- Department of Anaesthesia, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - William Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Vickie Yeardley
- Imperial College Healthcare NHS Trust, London, UK
- Central London Community Healthcare NHS Trust, London, UK
| | - David K Menon
- Division of Perioperative, Acute, and Critical care, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Department of Clinical Neurosurgery, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
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McCabe JJ, Evans NR, Gorey S, Bhakta S, Rudd JHF, Kelly PJ. Imaging Carotid Plaque Inflammation Using Positron Emission Tomography: Emerging Role in Clinical Stroke Care, Research Applications, and Future Directions. Cells 2023; 12:2073. [PMID: 37626883 PMCID: PMC10453446 DOI: 10.3390/cells12162073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023] Open
Abstract
Atherosclerosis is a chronic systemic inflammatory condition of the vasculature and a leading cause of stroke. Luminal stenosis severity is an important factor in determining vascular risk. Conventional imaging modalities, such as angiography or duplex ultrasonography, are used to quantify stenosis severity and inform clinical care but provide limited information on plaque biology. Inflammatory processes are central to atherosclerotic plaque progression and destabilization. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a validated technique for quantifying plaque inflammation. In this review, we discuss the evolution of FDG-PET as an imaging modality to quantify plaque vulnerability, challenges in standardization of image acquisition and analysis, its potential application to routine clinical care after stroke, and the possible role it will play in future drug discovery.
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Affiliation(s)
- John J. McCabe
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
| | - Nicholas R. Evans
- Department of Clinical Neurosciences, Box 83, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK; (N.R.E.); (S.B.)
| | - Sarah Gorey
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
| | - Shiv Bhakta
- Department of Clinical Neurosciences, Box 83, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK; (N.R.E.); (S.B.)
| | - James H. F. Rudd
- Division of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK;
| | - Peter J. Kelly
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
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Herlekar R, Sur Roy A, Hajiev S, Induruwa I, Agarwal S, Evans NR, Khadjooi K, Markus H, O’Brien E, Warburton E, Zachariah G, McCabe JJ. The contribution of competing mechanisms in stroke despite anticoagulation in patients with atrial fibrillation. Eur Stroke J 2023; 8:541-548. [PMID: 37231697 PMCID: PMC10334183 DOI: 10.1177/23969873231168367] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/20/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND For reasons poorly understood, strokes frequently occur in patients with atrial fibrillation (AF) despite oral anticoagulation. Better data are needed to inform randomised trials (RCTs) of new strategies to prevent recurrence in these patients. We investigate the relative contribution of competing stroke mechanisms in patients with AF who have stroke despite anticoagulation (OAC+) compared with those who are anticoagulant naïve (OAC-) at the time of their event. PATIENTS AND METHODS We performed a cross-sectional study leveraging data from a prospective stroke registry (2015-2022). Eligible patients had ischemic stroke and AF. Stroke classification was performed by a single stroke-specialist blinded to OAC status using TOAST criteria. The presence of atherosclerotic plaque was determined using duplex ultrasonography, computerised tomography (CT) or magnetic resonance (MR) angiography. Imaging was reviewed by a single reader. Logistic regression was used to identify independent predictors of stroke despite anticoagulation. RESULTS Of 596 patients included, 198 (33.2%) were in the OAC+ group. A competing cause for stroke was more frequent in patients with OAC+ versus OAC- (69/198 (34.8%)) versus 77/398 (19.3%), p < 0.001). After adjustment, both small vessel occlusion (odds ratio (OR): 2.46, 95% CI: 1.20-5.06) and arterial atheroma (⩾50% stenosis) (OR: 1.78, 95% CI: 1.07-2.94) were independently associated with stroke despite anticoagulation. DISCUSSION AND CONCLUSION Patients with AF-associated stroke despite OAC are much more likely than patients who are OAC-naïve to have competing stroke mechanisms. Rigorous investigation for alternative stroke causes in stroke despite OAC has a high diagnostic yield. These data should be used to guide patient selection for future RCTs in this population.
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Affiliation(s)
- Rahul Herlekar
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Akangsha Sur Roy
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Saur Hajiev
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Isuru Induruwa
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Smriti Agarwal
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Kayvan Khadjooi
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Hugh Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Eoin O’Brien
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - George Zachariah
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - John J McCabe
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Dublin, Ireland
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Dublin, Ireland
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7
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Evans NR, Tarkin JM, Walsh J, Chowdhury MM, Patterson AJ, Graves MJ, Rudd JHF, Warburton EA. Carotid Atheroinflammation Is Associated With Cerebral Small Vessel Disease Severity. Front Neurol 2021; 12:690935. [PMID: 34531813 PMCID: PMC8438317 DOI: 10.3389/fneur.2021.690935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/30/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Atherosclerosis is a systemic inflammatory disease, with common inflammatory processes implicated in both atheroma vulnerability and blood-brain barrier disruption. This prospective multimodal imaging study aimed to measure directly the association between systemic atheroma inflammation (“atheroinflammation”) and downstream chronic cerebral small vessel disease severity. Methods: Twenty-six individuals with ischemic stroke with ipsilateral carotid artery stenosis of >50% underwent 18fluoride-fluorodeoxyglucose-positron emission tomography within 2 weeks of stroke. Small vessel disease severity and white matter hyperintensity volume were assessed using 3-tesla magnetic resonance imaging also within 2 weeks of stroke. Results: Fluorodeoxyglucose uptake was independently associated with more severe small vessel disease (odds ratio 6.18, 95% confidence interval 2.1–18.2, P < 0.01 for the non-culprit carotid artery) and larger white matter hyperintensity volumes (coefficient = 14.33 mL, P < 0.01 for the non-culprit carotid artery). Conclusion: These proof-of-concept results have important implications for our understanding of the neurovascular interface and potential therapeutic exploitation in the management of systemic atherosclerosis, particularly non-stenotic disease previously considered asymptomatic, in order to reduce the burden of chronic cerebrovascular disease.
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Affiliation(s)
- Nicholas R Evans
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom.,Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jason M Tarkin
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jessica Walsh
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | | | - Andrew J Patterson
- Department of Radiology, University of Cambridge, Cambridge, United Kingdom
| | - Martin J Graves
- Department of Radiology, University of Cambridge, Cambridge, United Kingdom
| | - James H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Elizabeth A Warburton
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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Evans NR, Todd OM, Minhas JS, Fearon P, Harston GW, Mant J, Mead G, Hewitt J, Quinn TJ, Warburton EA. Frailty and cerebrovascular disease: Concepts and clinical implications for stroke medicine. Int J Stroke 2021; 17:251-259. [PMID: 34282986 PMCID: PMC8864332 DOI: 10.1177/17474930211034331] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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: 11/23/2022]
Abstract
Frailty is a distinctive health state in which the ability of older people to cope with
acute stressors is compromised by an increased vulnerability brought by age-associated
declines in physiological reserve and function across multiple organ systems. Although
closely associated with age, multimorbidity, and disability, frailty is a discrete
syndrome that is associated with poorer outcomes across a range of medical conditions.
However, its role in cerebrovascular disease and stroke has received limited attention.
The estimated rise in the prevalence of frailty associated with changing demographics over
the coming decades makes it an important issue for stroke practitioners, cerebrovascular
research, clinical service provision, and stroke survivors alike. This review will
consider the concept and models of frailty, how frailty is common in cerebrovascular
disease, the impact of frailty on stroke risk factors, acute treatments, and
rehabilitation, and considerations for future applications in both cerebrovascular
clinical and research settings.
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Affiliation(s)
| | - Oliver M Todd
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Jatinder S Minhas
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Patricia Fearon
- Department of Stroke Medicine, Royal Victoria Hospital, Belfast, UK
| | - George W Harston
- Acute Stroke Programme, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jonathan Mant
- Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Gillian Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jonathan Hewitt
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Sriranjan RS, Tarkin JM, Evans NR, Le EPV, Chowdhury MM, Rudd JHF. Atherosclerosis imaging using PET: Insights and applications. Br J Pharmacol 2021; 178:2186-2203. [PMID: 31517992 DOI: 10.1111/bph.14868] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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] [Received: 03/28/2019] [Revised: 08/02/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022] Open
Abstract
PET imaging is able to harness biological processes to characterise high-risk features of atherosclerotic plaque prone to rupture. Current radiotracers are able to track inflammation, microcalcification, hypoxia, and neoangiogenesis within vulnerable plaque. 18 F-fluorodeoxyglucose (18 F-FDG) is the most commonly used radiotracer in vascular studies and is employed as a surrogate marker of plaque inflammation. Increasingly, 18 F-FDG and other PET tracers are also being used to provide imaging endpoints in cardiovascular interventional trials. The evolution of novel PET radiotracers, imaging protocols, and hybrid scanners are likely to enable more efficient and accurate characterisation of high-risk plaque. This review explores the role of PET imaging in atherosclerosis with a focus on PET tracers utilised in clinical research and the applications of PET imaging to cardiovascular drug development.
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Affiliation(s)
| | - Jason M Tarkin
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Nicholas R Evans
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Elizabeth P V Le
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | | | - James H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
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Le EPV, Rundo L, Tarkin JM, Evans NR, Chowdhury MM, Coughlin PA, Pavey H, Wall C, Zaccagna F, Gallagher FA, Huang Y, Sriranjan R, Le A, Weir-McCall JR, Roberts M, Gilbert FJ, Warburton EA, Schönlieb CB, Sala E, Rudd JHF. Assessing robustness of carotid artery CT angiography radiomics in the identification of culprit lesions in cerebrovascular events. Sci Rep 2021; 11:3499. [PMID: 33568735 PMCID: PMC7876096 DOI: 10.1038/s41598-021-82760-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/21/2021] [Indexed: 02/02/2023] Open
Abstract
Radiomics, quantitative feature extraction from radiological images, can improve disease diagnosis and prognostication. However, radiomic features are susceptible to image acquisition and segmentation variability. Ideally, only features robust to these variations would be incorporated into predictive models, for good generalisability. We extracted 93 radiomic features from carotid artery computed tomography angiograms of 41 patients with cerebrovascular events. We tested feature robustness to region-of-interest perturbations, image pre-processing settings and quantisation methods using both single- and multi-slice approaches. We assessed the ability of the most robust features to identify culprit and non-culprit arteries using several machine learning algorithms and report the average area under the curve (AUC) from five-fold cross validation. Multi-slice features were superior to single for producing robust radiomic features (67 vs. 61). The optimal image quantisation method used bin widths of 25 or 30. Incorporating our top 10 non-redundant robust radiomics features into ElasticNet achieved an AUC of 0.73 and accuracy of 69% (compared to carotid calcification alone [AUC: 0.44, accuracy: 46%]). Our results provide key information for introducing carotid CT radiomics into clinical practice. If validated prospectively, our robust carotid radiomic set could improve stroke prediction and target therapies to those at highest risk.
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Affiliation(s)
| | - Leonardo Rundo
- Department of Radiology, University of Cambridge, Cambridge, UK
- Cancer Research UK Cambridge Centre, University of Cambridge, Cambridge, UK
| | - Jason M Tarkin
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Nicholas R Evans
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mohammed M Chowdhury
- Division of Vascular Surgery, Department of Surgery, University of Cambridge, Cambridge, UK
| | - Patrick A Coughlin
- Division of Vascular Surgery, Department of Surgery, University of Cambridge, Cambridge, UK
| | - Holly Pavey
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK
| | - Chris Wall
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Fulvio Zaccagna
- Department of Radiology, University of Cambridge, Cambridge, UK
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | | | - Yuan Huang
- Department of Radiology, University of Cambridge, Cambridge, UK
- EPSRC Centre for Mathematical Imaging in Healthcare, University of Cambridge, Cambridge, UK
| | | | - Anthony Le
- School of Medicine, University of Leeds, Leeds, UK
| | | | - Michael Roberts
- EPSRC Centre for Mathematical Imaging in Healthcare, University of Cambridge, Cambridge, UK
- Oncology R&D, AstraZeneca, Cambridge, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
| | - Fiona J Gilbert
- Department of Radiology, University of Cambridge, Cambridge, UK
| | | | - Carola-Bibiane Schönlieb
- EPSRC Centre for Mathematical Imaging in Healthcare, University of Cambridge, Cambridge, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
| | - Evis Sala
- Department of Radiology, University of Cambridge, Cambridge, UK
- Cancer Research UK Cambridge Centre, University of Cambridge, Cambridge, UK
| | - James H F Rudd
- Department of Medicine, University of Cambridge, Cambridge, UK.
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Affiliation(s)
- Nicholas R Evans
- Department of Medicine, University of Cambridge, United Kingdom (N.R.E)
| | - Jatinder S Minhas
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, United Kingdom (J.S.M., A.K.M.)
| | - Zehra Mehdi
- Department of Stroke Medicine, Hampshire Hospitals NHS Foundation Trust, United Kingdom (Z.M.)
| | - Amit K Mistri
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, United Kingdom (J.S.M., A.K.M.)
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Karunanantham J, Ali JM, Evans NR, Webb S, Large SR. Impact of stroke on outcomes following cardiac surgery: Propensity matched analysis. J Card Surg 2020; 35:3010-3016. [DOI: 10.1111/jocs.14964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Jason M. Ali
- Department of Cardiothoracic Surgery University of Cambridge Cambridge UK
| | | | - Stephen Webb
- Department of Intensive Care Royal Papworth Hospital Cambridge UK
| | - Stephen R. Large
- Department of Cardiothoracic Surgery University of Cambridge Cambridge UK
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Evans NR, Wall J, To B, Wallis SJ, Romero-Ortuno R, Warburton EA. Clinical frailty independently predicts early mortality after ischaemic stroke. Age Ageing 2020; 49:588-591. [PMID: 31951248 DOI: 10.1093/ageing/afaa004] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/14/2019] [Accepted: 01/05/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Clinical frailty is an important syndrome for clinical care and research, independently predicting mortality and rates of institutionalisation in a range of medical conditions. However, there has been little research into the role of frailty in stroke. OBJECTIVE This study investigates the effect of frailty on 28-day mortality following ischaemic stroke and outcomes following stroke thrombolysis. METHODS Frailty was measured using the Clinical Frailty Scale (CFS) for all ischaemic stroke admissions aged ≥75 years. Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS). 28-day mortality and clinical outcomes were collected retrospectively. Analysis included both dichotomised measures of frailty (non-frail: CFS 1-4, frail: 5-8) and CFS as a continuous ordinal scale. RESULTS In 433 individuals with ischaemic stroke, 28-day mortality was higher in frail versus non-frail individuals (39 (16.7%) versus 10 (5%), P < 0.01). On multivariable analysis, a one-point increase in CFS was independently associated with 28-day mortality (OR 1.03 (1.01-1.05)). In 63 thrombolysed individuals, median NIHSS reduced significantly in non-frail individuals (12.5 (interquartile range (IQR) 9.25) to 5 (IQR 10.5), P < 0.01) but not in frail individuals (15 (IQR 11.5) to 16 (IQR 16.5), P = 0.23). On multivariable analysis, a one-point increase in CFS was independently associated with a one-point reduction in post-thrombolysis NIHSS improvement (coefficient 1.07, P = 0.03). CONCLUSION Clinical frailty is independently associated with 28-day mortality after ischaemic stroke and appears independently associated with attenuated improvement in NIHSS following stroke thrombolysis. Further research is needed to elucidate the underlying mechanisms and how frailty may be utilised in clinical decision-making.
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Affiliation(s)
- Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jasmine Wall
- Department of Medicine for the Elderly, Addenbrooke’s Hospital, Cambridge. UK
| | - Benjaman To
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Stephen J Wallis
- Department of Medicine for the Elderly, Addenbrooke’s Hospital, Cambridge. UK
| | - Roman Romero-Ortuno
- Department of Medicine for the Elderly, Addenbrooke’s Hospital, Cambridge. UK
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Evans NR, Tarkin JM, Le EP, Sriranjan RS, Corovic A, Warburton EA, Rudd JH. Integrated cardiovascular assessment of atherosclerosis using PET/MRI. Br J Radiol 2020; 93:20190921. [PMID: 32238077 DOI: 10.1259/bjr.20190921] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Atherosclerosis is a systemic inflammatory disease typified by the development of lipid-rich atheroma (plaques), the rupture of which are a major cause of myocardial infarction and stroke. Anatomical evaluation of the plaque considering only the degree of luminal stenosis overlooks features associated with vulnerable plaques, such as high-risk morphological features or pathophysiology, and hence risks missing vulnerable or ruptured non-stenotic plaques. Consequently, there has been interest in identifying these markers of vulnerability using either MRI for morphology, or positron emission tomography (PET) for physiological processes involved in atherogenesis. The advent of hybrid PET/MRI scanners offers the potential to combine the strengths of PET and MRI to allow comprehensive assessment of the atherosclerotic plaque. This review will discuss the principles and technical aspects of hybrid PET/MRI assessment of atherosclerosis, and consider how combining the complementary modalities of PET and MRI has already furthered our understanding of atherogenesis, advanced drug development, and how it may hold potential for clinical application.
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Affiliation(s)
- Nicholas R Evans
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jason M Tarkin
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Elizabeth Pv Le
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Rouchelle S Sriranjan
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Andrej Corovic
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Elizabeth A Warburton
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - James Hf Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
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Chowdhury MM, Tarkin JM, Albaghdadi MS, Evans NR, Le EP, Berrett TB, Sadat U, Joshi FR, Warburton EA, Buscombe JR, Hayes PD, Dweck MR, Newby DE, Rudd JH, Coughlin PA. Vascular Positron Emission Tomography and Restenosis in Symptomatic Peripheral Arterial Disease: A Prospective Clinical Study. JACC Cardiovasc Imaging 2020; 13:1008-1017. [PMID: 31202739 PMCID: PMC7136751 DOI: 10.1016/j.jcmg.2019.03.031] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 03/26/2019] [Accepted: 04/12/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study determined whether in vivo positron emission tomography (PET) of arterial inflammation (18F-fluorodeoxyglucose [18F-FDG]) or microcalcification (18F-sodium fluoride [18F-NaF]) could predict restenosis following PTA. BACKGROUND Restenosis following lower limb percutaneous transluminal angioplasty (PTA) is common, unpredictable, and challenging to treat. Currently, it is impossible to predict which patient will suffer from restenosis following angioplasty. METHODS In this prospective observational cohort study, 50 patients with symptomatic peripheral arterial disease underwent 18F-FDG and 18F-NaF PET/computed tomography (CT) imaging of the superficial femoral artery before and 6 weeks after angioplasty. The primary outcome was arterial restenosis at 12 months. RESULTS Forty subjects completed the study protocol with 14 patients (35%) reaching the primary outcome of restenosis. The baseline activities of femoral arterial inflammation (18F-FDG tissue-to-background ratio [TBR] 2.43 [interquartile range (IQR): 2.29 to 2.61] vs. 1.63 [IQR: 1.52 to 1.78]; p < 0.001) and microcalcification (18F-NaF TBR 2.61 [IQR: 2.50 to 2.77] vs. 1.69 [IQR: 1.54 to 1.77]; p < 0.001) were higher in patients who developed restenosis. The predictive value of both 18F-FDG (cut-off TBRmax value of 1.98) and 18F-NaF (cut-off TBRmax value of 2.11) uptake demonstrated excellent discrimination in predicting 1-year restenosis (Kaplan Meier estimator, log-rank p < 0.001). CONCLUSIONS Baseline and persistent femoral arterial inflammation and micro-calcification are associated with restenosis following lower limb PTA. For the first time, we describe a method of identifying complex metabolically active plaques and patients at risk of restenosis that has the potential to select patients for intervention and to serve as a biomarker to test novel interventions to prevent restenosis.
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Affiliation(s)
- Mohammed M. Chowdhury
- Division of Vascular Surgery, Department of Surgery, Addenbrooke’s Hospital, University of Cambridge, United Kingdom,Department of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, United Kingdom,Address for correspondence: Mr. Mohammed M. Chowdhury, Divisions of Vascular Surgery and Cardiovascular Medicine, University of Cambridge, Box 212, Addenbrooke’s Cambridge University Hospital, Hills Road, Cambridge CB2 2QQ, United Kingdom.
| | - Jason M. Tarkin
- Department of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
| | - Mazen S. Albaghdadi
- Cardiovascular Research Center, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicholas R. Evans
- Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Elizabeth P.V. Le
- Department of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
| | - Thomas B. Berrett
- Statistical Laboratory, Department of Pure Mathematics and Mathematical Sciences, University of Cambridge, United Kingdom
| | - Umar Sadat
- Division of Vascular Surgery, Department of Surgery, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
| | | | | | - John R. Buscombe
- Department of Nuclear Medicine, Addenbrooke’s Hospital, University of Cambridge United Kingdom
| | - Paul D. Hayes
- Division of Vascular Surgery, Department of Surgery, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
| | - Marc R. Dweck
- British Heart Foundation for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E. Newby
- British Heart Foundation for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - James H.F. Rudd
- Department of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
| | - Patrick A. Coughlin
- Division of Vascular Surgery, Department of Surgery, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
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Tarkin JM, Calcagno C, Dweck MR, Evans NR, Chowdhury MM, Gopalan D, Newby DE, Fayad ZA, Bennett MR, Rudd JH. 68Ga-DOTATATE PET Identifies Residual Myocardial Inflammation and Bone Marrow Activation After Myocardial Infarction. J Am Coll Cardiol 2020; 73:2489-2491. [PMID: 31097170 PMCID: PMC6525109 DOI: 10.1016/j.jacc.2019.02.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - James H.F. Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Level 6, Box 110, ACCI, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, United Kingdom @jhfrudd
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17
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Evans NR, Tarkin JM, Chowdhury MM, Le EPV, Coughlin PA, Rudd JHF, Warburton EA. Dual-Tracer Positron-Emission Tomography for Identification of Culprit Carotid Plaques and Pathophysiology In Vivo. Circ Cardiovasc Imaging 2020; 13:e009539. [PMID: 32164454 DOI: 10.1161/circimaging.119.009539] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inflammation and microcalcification are interrelated processes contributing to atherosclerotic plaque vulnerability. Positron-emission tomography can quantify these processes in vivo. This study investigates (1) 18F-fluorodeoxyglucose (FDG) and 18F-sodium fluoride (NaF) uptake in culprit versus nonculprit carotid atheroma, (2) spatial distributions of uptake, and (3) how macrocalcification affects this relationship. METHODS Individuals with acute ischemic stroke with ipsilateral carotid stenosis of ≥50% underwent FDG-positron-emission tomography and NaF-positron-emission tomography. Tracer uptake was quantified using maximum tissue-to-background ratios (TBRmax) and macrocalcification quantified using Agatston scoring. RESULTS In 26 individuals, median most diseased segment TBRmax (interquartile range) was higher in culprit than in nonculprit atheroma for both FDG (2.08 [0.52] versus 1.89 [0.40]; P<0.001) and NaF (2.68 [0.63] versus 2.39 [1.02]; P<0.001). However, whole vessel TBRmax was higher in culprit arteries for FDG (1.92 [0.41] versus 1.71 [0.31]; P<0.001) but not NaF (1.85 [0.28] versus 1.79 [0.60]; P=0.10). NaF uptake was concentrated at carotid bifurcations, while FDG was distributed evenly throughout arteries. Correlations between FDG and NaF TBRmax differed between bifurcations with low macrocalcification (rs=0.38; P<0.001) versus high macrocalcification (rs=0.59; P<0.001). CONCLUSIONS This is the first study to demonstrate increased uptake of both FDG and NaF in culprit carotid plaques, with discrete distributions of pathophysiology influencing vulnerability in vivo. These findings have implications for our understanding of the natural history of the disease and for the clinical assessment and management of carotid atherosclerosis.
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Affiliation(s)
- Nicholas R Evans
- Department of Clinical Neurosciences (N.R.E., E.A.W.), University of Cambridge, Cambridge, United Kingdom.,Department of Medicine (N.R.E., J.M.T., E.P.V.L., J.H.F.R.), University of Cambridge, Cambridge, United Kingdom
| | - Jason M Tarkin
- Department of Medicine (N.R.E., J.M.T., E.P.V.L., J.H.F.R.), University of Cambridge, Cambridge, United Kingdom
| | - Mohammed M Chowdhury
- Division of Vascular Surgery (M.M.C., P.A.C.), University of Cambridge, Cambridge, United Kingdom
| | - Elizabeth P V Le
- Department of Medicine (N.R.E., J.M.T., E.P.V.L., J.H.F.R.), University of Cambridge, Cambridge, United Kingdom
| | - Patrick A Coughlin
- Division of Vascular Surgery (M.M.C., P.A.C.), University of Cambridge, Cambridge, United Kingdom
| | - James H F Rudd
- Department of Medicine (N.R.E., J.M.T., E.P.V.L., J.H.F.R.), University of Cambridge, Cambridge, United Kingdom
| | - Elizabeth A Warburton
- Department of Clinical Neurosciences (N.R.E., E.A.W.), University of Cambridge, Cambridge, United Kingdom
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Tarkin JM, Le EPV, Calcagno C, Dweck MR, Evans NR, Chowdhury MM, Newby DE, Fayad ZA, Bennett MR, Rudd JHF. P30 68Ga-DOTATATE PET IDENTIFIES MYOCARDIAL INFLAMMATION AND BONE MARROW MONOCYTE MOBILISATION AFTER MYOCARDIAL INFARCTION. Cardiovasc Res 2018. [DOI: 10.1093/cvr/cvy216.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J M Tarkin
- Division of Cardiovascular Medicine, University of Cambridge
- National Heart & Lung Institute, Imperial College London
| | - E P V Le
- Division of Cardiovascular Medicine, University of Cambridge
| | - C Calcagno
- Translational & Molecular Imaging Institute and Department of Radiology, Icahn School of Medicine at Mount Sinai, New York
| | - M R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh
| | - N R Evans
- Department of Clinical Neurosciences, University of Cambridge
| | - M M Chowdhury
- Department of Vascular and Endovascular Surgery, Addenbrooke’s Hospital, Cambridge
| | - D E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh
| | - Z A Fayad
- Translational & Molecular Imaging Institute and Department of Radiology, Icahn School of Medicine at Mount Sinai, New York
| | - M R Bennett
- Division of Cardiovascular Medicine, University of Cambridge
| | - J H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge
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Evans NR, Tarkin JM, Buscombe JR, Markus HS, Rudd JHF, Warburton EA. Erratum: PET imaging of the neurovascular interface in cerebrovascular disease. Nat Rev Neurol 2018; 14:313. [DOI: 10.1038/nrneurol.2018.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Evans NR, Tarkin JM, Buscombe JR, Markus HS, Rudd JHF, Warburton EA. PET imaging of the neurovascular interface in cerebrovascular disease. Nat Rev Neurol 2017; 13:676-688. [PMID: 28984315 DOI: 10.1038/nrneurol.2017.129] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cerebrovascular disease encompasses a range of pathologies that affect different components of the cerebral vasculature and brain parenchyma. Large artery atherosclerosis, acute cerebral ischaemia, and intracerebral small vessel disease all demonstrate altered metabolic processes that are key to their pathogenesis. Although structural imaging techniques such as MRI are the mainstay of clinical care and research in cerebrovascular disease, they have limited ability to detect these pathophysiological processes in vivo. By contrast, PET can detect and quantify metabolic processes that are relevant to each facet of cerebrovascular disease. Information obtained from PET studies has helped to shape the understanding of key concepts in cerebrovascular medicine, including vulnerable atherosclerotic plaque, salvageable ischaemic penumbra, neuroinflammation and selective neuronal loss after ischaemic insult. PET has also helped to elucidate the relationships between chronic hypoxia, neuroinflammation, and amyloid-β deposition in cerebral small vessel disease. This Review describes how PET-based imaging of metabolic processes at the neurovascular interface has contributed to our understanding of cerebrovascular disease.
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Affiliation(s)
- Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Box 83, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Jason M Tarkin
- Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Box 157, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - John R Buscombe
- Department of Nuclear Medicine, Box 219, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Box 83, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - James H F Rudd
- Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Box 157, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Elizabeth A Warburton
- Department of Clinical Neurosciences, University of Cambridge, Box 83, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
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Tarkin JM, Joshi FR, Evans NR, Chowdhury MM, Figg NL, Shah AV, Starks LT, Martin-Garrido A, Manavaki R, Yu E, Kuc RE, Grassi L, Kreuzhuber R, Kostadima MA, Frontini M, Kirkpatrick PJ, Coughlin PA, Gopalan D, Fryer TD, Buscombe JR, Groves AM, Ouwehand WH, Bennett MR, Warburton EA, Davenport AP, Rudd JHF. Detection of Atherosclerotic Inflammation by 68Ga-DOTATATE PET Compared to [ 18F]FDG PET Imaging. J Am Coll Cardiol 2017; 69:1774-1791. [PMID: 28385306 PMCID: PMC5381358 DOI: 10.1016/j.jacc.2017.01.060] [Citation(s) in RCA: 281] [Impact Index Per Article: 40.1] [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: 08/04/2016] [Revised: 01/04/2017] [Accepted: 01/20/2017] [Indexed: 10/25/2022]
Abstract
BACKGROUND Inflammation drives atherosclerotic plaque rupture. Although inflammation can be measured using fluorine-18-labeled fluorodeoxyglucose positron emission tomography ([18F]FDG PET), [18F]FDG lacks cell specificity, and coronary imaging is unreliable because of myocardial spillover. OBJECTIVES This study tested the efficacy of gallium-68-labeled DOTATATE (68Ga-DOTATATE), a somatostatin receptor subtype-2 (SST2)-binding PET tracer, for imaging atherosclerotic inflammation. METHODS We confirmed 68Ga-DOTATATE binding in macrophages and excised carotid plaques. 68Ga-DOTATATE PET imaging was compared to [18F]FDG PET imaging in 42 patients with atherosclerosis. RESULTS Target SSTR2 gene expression occurred exclusively in "proinflammatory" M1 macrophages, specific 68Ga-DOTATATE ligand binding to SST2 receptors occurred in CD68-positive macrophage-rich carotid plaque regions, and carotid SSTR2 mRNA was highly correlated with in vivo 68Ga-DOTATATE PET signals (r = 0.89; 95% confidence interval [CI]: 0.28 to 0.99; p = 0.02). 68Ga-DOTATATE mean of maximum tissue-to-blood ratios (mTBRmax) correctly identified culprit versus nonculprit arteries in patients with acute coronary syndrome (median difference: 0.69; interquartile range [IQR]: 0.22 to 1.15; p = 0.008) and transient ischemic attack/stroke (median difference: 0.13; IQR: 0.07 to 0.32; p = 0.003). 68Ga-DOTATATE mTBRmax predicted high-risk coronary computed tomography features (receiver operating characteristics area under the curve [ROC AUC]: 0.86; 95% CI: 0.80 to 0.92; p < 0.0001), and correlated with Framingham risk score (r = 0.53; 95% CI: 0.32 to 0.69; p <0.0001) and [18F]FDG uptake (r = 0.73; 95% CI: 0.64 to 0.81; p < 0.0001). [18F]FDG mTBRmax differentiated culprit from nonculprit carotid lesions (median difference: 0.12; IQR: 0.0 to 0.23; p = 0.008) and high-risk from lower-risk coronary arteries (ROC AUC: 0.76; 95% CI: 0.62 to 0.91; p = 0.002); however, myocardial [18F]FDG spillover rendered coronary [18F]FDG scans uninterpretable in 27 patients (64%). Coronary 68Ga-DOTATATE PET scans were readable in all patients. CONCLUSIONS We validated 68Ga-DOTATATE PET as a novel marker of atherosclerotic inflammation and confirmed that 68Ga-DOTATATE offers superior coronary imaging, excellent macrophage specificity, and better power to discriminate high-risk versus low-risk coronary lesions than [18F]FDG. (Vascular Inflammation Imaging Using Somatostatin Receptor Positron Emission Tomography [VISION]; NCT02021188).
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Affiliation(s)
- Jason M Tarkin
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | | | - Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Mohammed M Chowdhury
- Department of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Nichola L Figg
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Aarti V Shah
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Lakshi T Starks
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Abel Martin-Garrido
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Roido Manavaki
- Department of Radiology, University of Cambridge, Cambridge, United Kingdom
| | - Emma Yu
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Rhoda E Kuc
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, United Kingdom
| | - Luigi Grassi
- Department of Hematology, University of Cambridge, and National Health Service Blood and Transport, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Roman Kreuzhuber
- Department of Hematology, University of Cambridge, and National Health Service Blood and Transport, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Myrto A Kostadima
- Department of Hematology, University of Cambridge, and National Health Service Blood and Transport, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Mattia Frontini
- Department of Hematology, University of Cambridge, and National Health Service Blood and Transport, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | | | - Patrick A Coughlin
- Department of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Deepa Gopalan
- Department of Radiology, University of Cambridge, Cambridge, United Kingdom; Department of Radiology, Hammersmith Hospital, London, United Kingdom
| | - Tim D Fryer
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - John R Buscombe
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ashley M Groves
- Institute of Nuclear Medicine, University College London, London, United Kingdom
| | - Willem H Ouwehand
- Department of Hematology, University of Cambridge, and National Health Service Blood and Transport, Cambridge Biomedical Campus, Cambridge, United Kingdom; Department of Human Genetics, Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, United Kingdom
| | - Martin R Bennett
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Elizabeth A Warburton
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Anthony P Davenport
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, United Kingdom
| | - James H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom.
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22
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Tarkin JM, Joshi FR, Evans NR, Chowdhury MM, Figg NL, Shah AV, Starks LT, Martin-Garrido A, Manavaki R, Yu E, Kuc RE, Grassi L, Kreuzhuber R, Kostadima MA, Frontini M, Kirkpatrick PJ, Coughlin PA, Gopalan D, Fryer TD, Buscombe JR, Groves AM, Ouwehand WH, Bennett MR, Warburton EA, Davenport AP, Rudd JHF. D Atherosclerotic inflammation imaging using 68ga-dotatate pet vs. 18f-fdg pet: a prospective clinical sudy with molecular and histological validation. Heart 2017. [DOI: 10.1136/heartjnl-2017-311726.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
Atherosclerotic diseases account for nearly half of all deaths and are leading causes of adult disability. Our understanding of how atherosclerosis leads to cardiovascular disease events has evolved: from a concept of progressive luminal narrowing, to that of sudden rupture and thrombosis of biologically active atheroma. In concert with this conceptual shift, contemporary imaging techniques now allow imaging of biological processes that associate with plaque instability: active calcification and plaque inflammation. This review focuses on opportunities provided by positron emission tomography/computed tomography, to identify these high-risk biological features of atherosclerosis.
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Affiliation(s)
- Basma Hammad
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicholas R Evans
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - James H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Ahmed Tawakol
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Integrative Bio-Imaging Program and Cardiac MR PET CT Program, Cardiology Division, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA.
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Induruwa I, Evans NR, Aziz A, Reddy S, Khadjooi K, Romero-Ortuno R. 33CLINICAL FRAILTY IS AN INDEPENDENT PREDICTOR FOR ANTICOAGULATION PRESCRIBING IN THE OLDER PERSON. Age Ageing 2017. [DOI: 10.1093/ageing/afx055.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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25
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Induruwa I, Evans NR, Aziz A, Reddy S, Khadjooi K, Romero-Ortuno R. Clinical frailty is independently associated with non-prescription of anticoagulants in older patients with atrial fibrillation. Geriatr Gerontol Int 2017; 17:2178-2183. [DOI: 10.1111/ggi.13058] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/18/2017] [Accepted: 02/20/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Isuru Induruwa
- Department of Medicine for the Elderly; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
- Department of Clinical Neurosciences; University of Cambridge; Cambridge UK
| | - Nicholas R. Evans
- Department of Clinical Neurosciences; University of Cambridge; Cambridge UK
| | - Ayesha Aziz
- Department of Medicine for the Elderly; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Snigdha Reddy
- Department of Medicine for the Elderly; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Kayvan Khadjooi
- Department of Stroke Medicine; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Roman Romero-Ortuno
- Department of Medicine for the Elderly; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
- Clinical Gerontology Unit, Department of Public Health and Primary Care; University of Cambridge, Addenbrooke's Hospital; Cambridge UK
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26
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Giugliano DN, Berger AC, Meidl H, Pucci MJ, Rosato EL, Keith SW, Evans NR, Palazzo F. Do intraoperative pyloric interventions predict the need for postoperative endoscopic interventions after minimally invasive esophagectomy? Dis Esophagus 2017; 30:1-8. [PMID: 28375478 DOI: 10.1093/dote/dow034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Indexed: 12/11/2022]
Abstract
Intraoperative pyloric procedures are often performed during esophagectomies to reduce the rates of gastric conduit dysfunction. They include pyloroplasty (PP), pyloromyotomy (PM), and pylorus botulinum toxin type-A injections (BI). Despite these procedures, patients frequently warrant further endoscopic interventions. The aim of this study is to compare intraoperative pyloric procedures and the rates of postoperative endoscopic interventions following minimally invasive esophagectomy (MIE). We identified patients who underwent MIE for esophageal carcinoma and grouped them as 'None' (no intervention), 'PP', 'PM', or 'BI' based on intraoperative pyloric procedure type. The rates of endoscopic interventions for the first six postoperative months were compared. To adjust for variability due to MIE type, the rates of >1 interventions were compared using a zero-inflated Poisson regression analysis. Significance was established at P < 0.05. There were 146 patients who underwent an MIE for esophageal cancer from 2008 to 2015; 77.4% were three-hole MIE, and 22.6% were Ivor- Lewis MIE. BI was most frequent in Ivor-Lewis patients (63.5%), while PP was most frequent (46.9%) in three-hole patients. Postoperative endoscopic interventions occurred in 38 patients (26.0%). The BI group had the highest percentage of patients requiring a postoperative intervention (n = 13, 31.7%). After adjusting for higher rates of interventions in three-hole MIE patients, the BI and None groups had the lowest rates of >1 postoperative interventions. Our data did not show superiority of any pyloric intervention in preventing endoscopic interventions. The patients who received BI to the pylorus demonstrated a trend toward a greater likelihood of having a postoperative intervention. However when adjusted for type of MIE, the BI and None groups had lower rates of subsequent multiple interventions. Further research is needed to determine if the choice of intraoperative pyloric procedure type significantly affects quality of life, morbidity, and overall prognosis in these patients.
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Affiliation(s)
| | | | | | | | | | - S W Keith
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Evans NR, Tarkin JM, Chowdhury MM, Malani S, Rudd JH, Warburton EA. Abstract TMP29: Non-invasive Identification of Culprit Carotid Atheroma Using Sodium Fluoride-positron Emission Tomography. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.tmp29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Microcalcification is a histopathological feature of atheroma at risk of rupture; so-called “vulnerable plaques.” Positron emission tomography (PET) using
18
F-sodium fluoride (NaF) has been used to detect microcalcification in
ex vivo
histology, though its use
in vivo
has been limited. We investigated the utility of NaF-PET to identify culprit carotid artery atheroma non-invasively
in vivo
in the setting of acute ischemic stroke.
Methods:
Symptomatic carotid artery stenosis of ≥50% was imaged using NaF-PET within 14 days of ipsilateral ischemic stroke. Symptomatic arteries were compared to contralateral asymptomatic carotid arteries. NaF dose was 125 MBq with 60 minute uptake on a GE Discovery 690 with 64 slice computed tomography. NaF uptake was measured using standardized uptake values for each artery’s single region of maximum uptake (SUVmax) and the mean of the three slices representing the most diseased segment (MDS-SUVmax). Arteries were compared using Wilcoxon signed-rank testing.
Results:
Fifty-two carotid arteries were analyzed: 26 symptomatic, 26 asymptomatic. Median SUVmax was higher in symptomatic than asymptomatic arteries: 2.16 (IQR 0.76) and 1.88 (IQR 0.94) respectively (p<0.001). MDS-SUVmax was 2.04 (IQR 0.66) in symptomatic and 1.76 (IQR 0.83) in asymptomatic carotids (p<0.001). Calcium scores did not differ between symptomatic and asymptomatic arteries (p=0.34).
Conclusions:
The ability to identify culprit carotid atheroma using NaF-PET
in vivo
represents an important advance in vascular imaging. This has important implications for understanding atherosclerosis pathophysiology, as well as potential clinical applications to identify and risk-stratify vulnerable carotid atheroma.
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Affiliation(s)
- Nicholas R Evans
- Dept of Clinical Neurosciences, Univ of Cambridge, Cambridge, United Kingdom
| | - Jason M Tarkin
- Div of Cardiovascular Medicine, Dept of Medicine, Univ of Cambridge, Cambridge, United Kingdom
| | - Mohammed M Chowdhury
- Div of Vascular and Endovascular Surgery, Cambridge Univ Hosps NHS Foundation Trust, Cambridge, United Kingdom
| | - Sangam Malani
- Dept of Clinical Neurosciences, Univ of Cambridge, Cambridge, United Kingdom
| | - James H Rudd
- Div of Cardiovascular Medicine, Dept of Medicine, Univ of Cambridge, Cambridge, United Kingdom
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Evans NR, Tarkin JM, Chowdhury MM, Warburton EA, Rudd JHF. PET Imaging of Atherosclerotic Disease: Advancing Plaque Assessment from Anatomy to Pathophysiology. Curr Atheroscler Rep 2016; 18:30. [PMID: 27108163 PMCID: PMC4842219 DOI: 10.1007/s11883-016-0584-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atherosclerosis is a leading cause of morbidity and mortality. It is now widely recognized that the disease is more than simply a flow-limiting process and that the atheromatous plaque represents a nidus for inflammation with a consequent risk of plaque rupture and atherothrombosis, leading to myocardial infarction or stroke. However, widely used conventional clinical imaging techniques remain anatomically focused, assessing only the degree of arterial stenosis caused by plaques. Positron emission tomography (PET) has allowed the metabolic processes within the plaque to be detected and quantified directly. The increasing armory of radiotracers has facilitated the imaging of distinct metabolic aspects of atherogenesis and plaque destabilization, including macrophage-mediated inflammatory change, hypoxia, and microcalcification. This imaging modality has not only furthered our understanding of the disease process in vivo with new insights into mechanisms but has also been utilized as a non-invasive endpoint measure in the development of novel treatments for atherosclerotic disease. This review provides grounding in the principles of PET imaging of atherosclerosis, the radioligands in use and in development, its research and clinical applications, and future developments for the field.
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Affiliation(s)
- Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Jason M Tarkin
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Mohammed M Chowdhury
- Division of Vascular and Endovascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Elizabeth A Warburton
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - James H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
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29
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Affiliation(s)
- Thomas B Stoker
- Core Medical Trainee, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge
| | - Nicholas R Evans
- Clinical Research Fellow, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ
| | - Elizabeth A Warburton
- Consultant Stroke Physician, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge
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30
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Evans NR, Warne B, Wood DF. Developing a pragmatic medical curriculum for the 21st century. Med Educ 2016; 50:1192-1194. [PMID: 27873426 DOI: 10.1111/medu.13079] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/09/2015] [Accepted: 01/14/2016] [Indexed: 06/06/2023]
Abstract
Medical education within a hospital setting presents both opportunities and challenges. The range of educational experiences on offer is often vast, though may be lost in the overworked and convoluted environment of a tertiary centre. As our learners are increasingly consumed by the literal and figurative labyrinths of hospitals and electronic learning logs, are we failing to train them in the skills they need to deliver 21st century health care? In response to this problem we propose a FARCICAL approach: Fostering A Relevant Curriculum that Is Closer to Actual Life.
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Affiliation(s)
- Nicholas R Evans
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Ben Warne
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Diana F Wood
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
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31
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Sriranjan RS, Tarkin JM, Evans NR, Chowdhury MM, Rudd JH. Imaging unstable plaque. Q J Nucl Med Mol Imaging 2016; 60:205-218. [PMID: 27273430] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Recent advances in imaging technology have enabled us to utilise a range of diagnostic approaches to better characterise high-risk atherosclerotic plaque. The aim of this article is to review current and emerging techniques used to detect and quantify unstable plaque in the context of large and small arterial systems and will focus on both invasive and non-invasive imaging techniques. While the diagnosis of clinically relevant atherosclerosis still relies heavily on anatomical assessment of arterial luminal stenosis, evolving multimodal cross-sectional imaging techniques that encompass novel molecular probes can provide added information with regard to plaque composition and overall disease burden. Novel molecular probes currently being developed to track precursors of plaque rupture such as inflammation, micro-calcification, hypoxia and neoangiogenesis are likely to have translational applications beyond diagnostics and have the potential to play a part in quantifying early responses to therapeutic interventions and more accurate cardiovascular risk stratification.
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Affiliation(s)
- Rouchelle S Sriranjan
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, England, UK -
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32
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Stoker TB, Evans NR. Managing Risk After Intracerebral Hemorrhage in Concomitant Atrial Fibrillation and Cerebral Amyloid Angiopathy. Stroke 2016; 47:e190-2. [DOI: 10.1161/strokeaha.116.013323] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/17/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas B. Stoker
- From the Department of Stroke Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (T.B.S.); and Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom (N.R.E.)
| | - Nicholas R. Evans
- From the Department of Stroke Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (T.B.S.); and Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom (N.R.E.)
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Abstract
Advances in atherosclerosis imaging technology and research have provided a range of diagnostic tools to characterize high-risk plaque in vivo; however, these important vascular imaging methods additionally promise great scientific and translational applications beyond this quest. When combined with conventional anatomic- and hemodynamic-based assessments of disease severity, cross-sectional multimodal imaging incorporating molecular probes and other novel noninvasive techniques can add detailed interrogation of plaque composition, activity, and overall disease burden. In the catheterization laboratory, intravascular imaging provides unparalleled access to the world beneath the plaque surface, allowing tissue characterization and measurement of cap thickness with micrometer spatial resolution. Atherosclerosis imaging captures key data that reveal snapshots into underlying biology, which can test our understanding of fundamental research questions and shape our approach toward patient management. Imaging can also be used to quantify response to therapeutic interventions and ultimately help predict cardiovascular risk. Although there are undeniable barriers to clinical translation, many of these hold-ups might soon be surpassed by rapidly evolving innovations to improve image acquisition, coregistration, motion correction, and reduce radiation exposure. This article provides a comprehensive review of current and experimental atherosclerosis imaging methods and their uses in research and potential for translation to the clinic.
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Affiliation(s)
- Jason M Tarkin
- From the Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK (J.M.T., A.J.B., J.H.F.R.); Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK (N.R.E.); Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom (M.R.D); Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.P.T., A.T.); Imaging Sciences Laboratories, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F., M.R.D.); and Department of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F.)
| | - Marc R Dweck
- From the Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK (J.M.T., A.J.B., J.H.F.R.); Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK (N.R.E.); Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom (M.R.D); Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.P.T., A.T.); Imaging Sciences Laboratories, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F., M.R.D.); and Department of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F.)
| | - Nicholas R Evans
- From the Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK (J.M.T., A.J.B., J.H.F.R.); Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK (N.R.E.); Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom (M.R.D); Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.P.T., A.T.); Imaging Sciences Laboratories, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F., M.R.D.); and Department of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F.)
| | - Richard A P Takx
- From the Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK (J.M.T., A.J.B., J.H.F.R.); Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK (N.R.E.); Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom (M.R.D); Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.P.T., A.T.); Imaging Sciences Laboratories, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F., M.R.D.); and Department of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F.)
| | - Adam J Brown
- From the Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK (J.M.T., A.J.B., J.H.F.R.); Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK (N.R.E.); Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom (M.R.D); Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.P.T., A.T.); Imaging Sciences Laboratories, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F., M.R.D.); and Department of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F.)
| | - Ahmed Tawakol
- From the Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK (J.M.T., A.J.B., J.H.F.R.); Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK (N.R.E.); Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom (M.R.D); Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.P.T., A.T.); Imaging Sciences Laboratories, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F., M.R.D.); and Department of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F.)
| | - Zahi A Fayad
- From the Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK (J.M.T., A.J.B., J.H.F.R.); Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK (N.R.E.); Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom (M.R.D); Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.P.T., A.T.); Imaging Sciences Laboratories, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F., M.R.D.); and Department of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F.)
| | - James H F Rudd
- From the Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK (J.M.T., A.J.B., J.H.F.R.); Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK (N.R.E.); Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom (M.R.D); Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.P.T., A.T.); Imaging Sciences Laboratories, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F., M.R.D.); and Department of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (Z.A.F.).
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Affiliation(s)
- N R Evans
- From the Department of Clinical Neurosciences, University of Cambridge, R3 Clinical Neurosciences (Box 83), Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, United Kingdom
| | - M W Besser
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, United Kingdom
| | - K Khadjooi
- Department of Stroke Medicine, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, United Kingdom
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van Herwijnen B, Evans NR, Dare CJ, Davies EM. An intraoperative irrigation regimen to reduce the surgical site infection rate following adolescent idiopathic scoliosis surgery. Ann R Coll Surg Engl 2016; 98:320-3. [PMID: 27087324 PMCID: PMC5227047 DOI: 10.1308/rcsann.2016.0132] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The aim of this study was to compare the efficacy of a gentamicin antibiotic intraoperative irrigation regimen (regimen A) with a povidone-iodine intraoperative irrigation regimen (regimen B) and to evaluate the ability of adjunctive local vancomycin powder (regimen C) to reduce the surgical site infection (SSI) rate following idiopathic scoliosis correction. METHODS This was a retrospective, single centre, two-surgeon cohort study of paediatric scoliosis procedures involving 118 patients under the age of 18 years who underwent correction for idiopathic scoliosis over a period of 42 months. Patients' baseline characteristics, pseudarthrosis and rates of SSI were compared. RESULTS Baseline characteristics were comparable in all three groups, with the exception of sex distribution. Over a quarter (27%) of patients with regimen B were male compared with 13% and 6% for regimens A and C respectively. Patients were mostly followed up for a minimum of 12 months. The SSI rate for both superficial and deep infections was higher with regimen A (26.7%) than with regimens B and C (7.0% and 6.3% respectively). The SSI rates for regimens B and C were comparable. No patients developed complications related to vancomycin toxicity, metalwork failure or pseudarthrosis. CONCLUSIONS Wound irrigation with a povidone-iodine solution reduces SSIs following adolescent idiopathic scoliosis surgery. The direct application of vancomycin powder to the wound is safe but does not reduce the SSI rate further in low risk patients. Additional studies are needed to elucidate whether it is effective at higher doses and in high risk patient groups.
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Affiliation(s)
| | - N R Evans
- University Hospital Southampton NHS Foundation Trust , UK
| | - C J Dare
- University Hospital Southampton NHS Foundation Trust , UK
| | - E M Davies
- University Hospital Southampton NHS Foundation Trust , UK
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Tarkin J, Joshi FR, Evans NR, Groves A, Gopalan D, Manavaki R, Kirkpatrick PJ, Coughlin PA, Buscombe J, Fryer TD, Bennett M, Davenport A, Warburton EA, Rudd J. 68GA-DOTATATE VASCULAR INFLAMMATION IMAGING PREDICTS HIGH-RISK PLAQUE MORPHOLOGY AND CULPRIT CORONARY LESIONS. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)31578-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Choonoo JO, Hofmeyr R, Evans NR, James MF, Meyersfeld N. A new option in airway management: evaluation of the TotalTrack® video laryngeal mask. Southern African Journal of Anaesthesia and Analgesia 2016. [DOI: 10.1080/22201181.2016.1159784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Affiliation(s)
- N R Evans
- From the Department of Clinical Neurosciences, University of Cambridge, R3 Clinical Neurosciences (Box 83), Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK,
| | - V Harper
- Department of Stroke Medicine and
| | - D J Scoffings
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - E A Warburton
- From the Department of Clinical Neurosciences, University of Cambridge, R3 Clinical Neurosciences (Box 83), Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK
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Evans NR, Richardson LS, Dhatariya KK, Sampson MJ. Diabetes specialist nurse telemedicine: admissions avoidance, costs and casemix. ACTA ACUST UNITED AC 2015. [DOI: 10.1002/edn.198] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Evans NR, White AJP. (E)-5,5′-Di(thiophen-2-yl)-3,3′-bi[thiophen-3(2H)-ylidene]-2,2′-diones—from conspicuous blue impurities to “quasi-metallic” golden-bronze crystals. Org Biomol Chem 2013; 11:3871-9. [DOI: 10.1039/c3ob40373d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
This study aimed to investigate relationships between dysglycaemia and length of hospital stay, short-term mortality and readmission in an unselected population in an acute medical unit (AMU). The rate of follow up in non-diabetic individuals with hyperglycaemia was also measured. We analysed data from all 1,502 patients admitted through our AMU in February 2010 to assess blood glucose levels on admission, length of stay, 28-day readmissions and mortality, and to determine whether blood glucose > or = 11.1 mmol/l on admission in non-diabetic individuals was followed up. In total, blood glucose was measured on admission for 893 patients. Mean length of stay was 8.8 (standard deviation 11.9) days, for patients with blood glucose < 6.5 mmol/l on admission; 11.3 (13.6) days, for 6.5-7 mmol/l; 10.2 (14.5) days, for 7.1-9 mmol/l; 10.6 (14.9) days, for 9.1-11 mmol/l; 12 (18.4) days, for 11.1-20 mmol/l and 9.1 (11.2) days, for > 20.1 mmol/l. Length of stay for patients with blood glucose > 6.5 mmol/l on admission was significantly longer (p = 0.002). The 28-day readmission rates were 6.4%, 6%, 9.7%, 12.5%, 10% and 15%, respectively, and 28-day death rates were 4.8%, 6%, 5.8%, 17.2%, 17.1% and 6.1%, respectively. Overall, 51.4% of non-diabetic individuals with blood glucose > 11.1 mmol/l on admission were followed up. The study showed that blood glucose > 6.5 mmol/l on admission is associated with significantly longer length of stay. Hyperglycaemia was associated with increased 28-day mortality and readmissions, and is frequently underinvestigated.
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Affiliation(s)
- NR Evans
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich
| | - KK Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich
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Evans NR, Richardson LS, Dhatariya KK, Sampson MJ. Diabetes specialist nurse telemedicine: admissions avoidance, costs and casemix. Practical Diabetes 2012. [DOI: 10.1002/pdi.1652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Dawson JI, Kingham E, Evans NR, Tayton E, Oreffo RO. Skeletal Regeneration: application of nanotopography and biomaterials for skeletal stem cell based bone repair. Inflamm Regen 2012. [DOI: 10.2492/inflammregen.32.072] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Horst S, Evans NR, Bronstein HA, Williams CK. Synthesis of fluoro-substituted silole-containing conjugated materials. ACTA ACUST UNITED AC 2009. [DOI: 10.1002/pola.23563] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Tucker EM, Evans NR, Kilgour L. Close linkage between the C blood group locus and the locus controlling amino acid transport in sheep erythrocytes. Anim Blood Groups Biochem Genet 2009; 11:119-25. [PMID: 7436049 DOI: 10.1111/j.1365-2052.1980.tb01502.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Data from 838 Finnish Landrace or Finnish Landrace crossbred sheep showed a highly significant correlation between phenotypes of the C blood group system and erythrocyte amino acid transport variants. Erythrocytes with normal amino acid transport properties (GSH high, Ly- type) were Cb-positive or Cb-negative. Erythrocytes with the amino acid transport lesion (GSH low, Ly +) were never Cb-negative. Sheep erythrocytes homozygous for Cb showed stronger lysis reactions with anti-Cb than heterozygous cells. Ly + sheep were nearly always homozygous for Cb, whereas most Ly- sheep were heterozygous for Cb-negative. Inheritance studies provided strong evidence that this association is due to close genetic linkage.
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Evans NR, Sudha Devi L, Mak CSK, Watkins SE, Pascu SI, Köhler A, Friend RH, Williams CK, Holmes AB. Triplet Energy Back Transfer in Conjugated Polymers with Pendant Phosphorescent Iridium Complexes. J Am Chem Soc 2006; 128:6647-56. [PMID: 16704266 DOI: 10.1021/ja0584267] [Citation(s) in RCA: 210] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The nature of Dexter triplet energy transfer between bonded systems of a red phosphorescent iridium complex 13 and a conjugated polymer, polyfluorene, has been investigated in electrophosphorescent organic light-emitting diodes. Red-emitting phosphorescent iridium complexes based on the [Ir(btp)(2)(acac)] fragment (where btp is 2-(2'-benzo[b]thienyl)pyridinato and acac is acetylacetonate) have been attached either directly (spacerless) or through a -(CH(2))(8)- chain (octamethylene-tethered) at the 9-position of a 9-octylfluorene host. The resulting dibromo-functionalized spacerless (8) or octamethylene-tethered (12) fluorene monomers were chain extended by Suzuki polycondensations using the bis(boronate)-terminated fluorene macromonomers 16 in the presence of end-capping chlorobenzene solvent to produce the statistical spacerless (17) and octamethylene-tethered (18) copolymers containing an even dispersion of the pendant phosphorescent fragments. The spacerless monomer 12 adopts a face-to-face conformation with a separation of only 3.6 A between the iridium complex and fluorenyl group, as shown by X-ray analysis of a single crystal, and this facilitates intramolecular triplet energy transfer in the spacerless copolymers 17. The photo- and electroluminescence efficiencies of the octamethylene-tethered copolymers 18 are double those of the spacerless copolymers 17, and this is consistent with suppression of the back transfer of triplets from the red phosphorescent iridium complex to the polyfluorene backbone in 18. The incorporation of a -(CH(2))(8)- chain between the polymer host and phosphorescent guest is thus an important design principle for achieving higher efficiencies in those electrophosphorescent organic light-emitting diodes for which the triplet energy levels of the host and guest are similar.
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Affiliation(s)
- Nicholas R Evans
- Melville Laboratory for Polymer Synthesis, Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge CB2 1EW, UK
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Evans NR, Skowno JJ, Bennett PJ, James MF, Dyer RA. A prospective observational study of the use of the ProsealTM laryngeal mask airway for postpartum tubal ligation. Int J Obstet Anesth 2005; 14:90-5. [PMID: 15795142 DOI: 10.1016/j.ijoa.2004.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [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] [Received: 05/01/2004] [Revised: 09/01/2004] [Accepted: 10/01/2004] [Indexed: 11/25/2022]
Abstract
BACKGROUND Though controversial, the risk of pulmonary aspiration during general anaesthesia in the immediate postpartum period appears low. The efficacy of the Proseal laryngeal mask airway was studied prospectively in a group of patients undergoing postpartum tubal ligation. METHODS The Proseal laryngeal mask airway was employed for airway management in 90 fasted patients undergoing tubal ligation via minilaparotomy at least 8 h after normal vaginal delivery (mean 36.5, range 8-96 h). Gastric volume and pH were measured, using aspiration through a gastric tube. RESULT Proseal laryngeal mask airway insertion was successful in all patients, requiring one attempt in 75 patients (83%). The median (range) leak pressure was 35 (23-40) cmH2O. Twenty-two patients (25%) had a leak pressure of 40 cmH2O or greater. Gastric tube placement was successful in all patients, described as easy in 79 (87%), and difficult in 11 (13%). The mean initial volume of gastric aspirate was 10.7 (0-64) mL and the final volume 15.6 (0-71) mL. The mean pH of the gastric aspirate was 2.6 (1.2-6.6). There were no incidents of suspected fluid regurgitation or aspiration, but two patients required intubation during surgery. Ten patients (11.1%) complained of sore throat in the recovery room, nine of which were described as mild. All patients reported being satisfied with their anaesthesia. CONCLUSION The Proseal laryngeal mask airway provides an effective airway for general anaesthesia in fasted patients undergoing tubal ligation from 8 h after normal vaginal delivery. While the safety of an unprotected airway in this population remains uncertain, this study suggested a low risk of regurgitation, especially in the first 24 h post partum.
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Affiliation(s)
- N R Evans
- Department of Anaesthesia, University of Cape Town, Cape Town, South Africa
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Sandee AJ, Williams CK, Evans NR, Davies JE, Boothby CE, Köhler A, Friend RH, Holmes AB. Solution-Processible Conjugated Electrophosphorescent Polymers. J Am Chem Soc 2004; 126:7041-8. [PMID: 15174875 DOI: 10.1021/ja039445o] [Citation(s) in RCA: 263] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report the synthesis and photophysical study of a series of solution-processible phosphorescent iridium complexes. These comprise bis-cyclometalated iridium units [Ir(ppy)(2)(acac)] or [Ir(btp)(2)(acac)] where ppy is 2-phenylpyridinato, btp is 2-(2'-benzo[b]thienyl)pyridinato, and acac is acetylacetonate. The iridium units are covalently attached to and in conjugation with oligo(9,9-dioctylfluorenyl-2,7-diyl) [(FO)(n)] to form complexes [Ir(ppy-(FO)(n))(2)(acac)] or [Ir(btp-(FO)(n))(2)(acac)], where the number of fluorene units, n, is 1, 2, 3, approximately 10, approximately 20, approximately 30, or approximately 40. All the complexes exhibit emission from a mixed triplet state in both photoluminescence and electroluminescence, with efficient quenching of the fluorene singlet emission. Short-chain complexes, 11-13, [Ir(ppy-(FO)(n)-FH)(2)(acac)] where n = 0, 1, or 2, show green light emission, red-shifted through the FO attachment by about 70 meV, but for longer chains there is quenching because of the lower energy triplet state associated with polyfluorene. In contrast, polymer complexes 18-21 [Ir(btp-(FO)(n))(2)(acac)] where n is 5-40 have better triplet energy level matching and can be used to provide efficient red phosphorescent polymer light-emitting diodes, with a red shift due to the fluorene attachment of about 50 meV. We contrast this small (50-70 meV) and short-range modification of the triplet energies through extended conjugation, with the much more substantial evolution of the pi-pi* singlet transitions, which saturate at about n = 10. These covalently bound materials show improvements in efficiency over simple blends and will form the basis of future investigations into energy-transfer processes occurring in light-emitting diodes.
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Affiliation(s)
- Albertus J Sandee
- Melville Laboratory for Polymer Synthesis, Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge CB2 1EW, United Kingdom
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Abstract
This case describes the anaesthesia management of a patient with myasthenia gravis who required mastectomy with axillary lymph node clearance. After withholding medical therapy for the myasthenia preoperatively on the day of surgery, anaesthesia was maintained with halothane, nitrous oxide and a remifentanil infusion. Muscle relaxants were avoided, facilitated by the use of a ProSeal (Intravent, Orthofix, Maidenhead, United Kingdom) laryngeal mask airway for positive pressure ventilation. The ProSeal laryngeal mask airway is a new laryngeal mask device with a modified cuff and a drainage tube which has been shown to have advantages over older designs for use during positive pressure ventilation. The rationale for the management of this patient with myasthenia is discussed.
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Affiliation(s)
- S V Gardner
- Department of Anaesthesia, University of Cape Town, Groote Schuur Hospital, Observatory, South Africa
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Gardner SV, James MFM, Evans NR. Gender issues among South African anaesthetists. S Afr Med J 2002; 92:732-6. [PMID: 12382361] [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: 02/26/2023] Open
Abstract
OBJECTIVE To study gender issues among South African anaesthetists. SUBJECTS AND DESIGN A postal survey of all registered anaesthetists in South Africa in December 1999. RESULTS There were 385 respondents out of a potential 960, giving a response rate of 40%; 77 respondents (20%) were female and 308 (80%) were male. The largest group of males was over 50 years old whereas most females were under 50 years. Most respondents chose anaesthesia because of academic appeal or career opportunities. More females reported experiencing sexual harassment and felt discriminated against in terms of job selection during the training period and with regard to referral practices. Most respondents felt that their colleagues did not treat them differently on account of gender but more females felt that both patients and female nurses treated them less favourably than their male colleagues. More males felt supported in their career by their life partners. More females felt that having children adversely affected academic and promotional aspects of their careers. Despite this, females were more likely to have experienced positive benefits from combining parenting with a career and were also more likely to have worked part time, mainly because of domestic commitments. Most respondents were satisfied with their careers, and would choose both medicine and anaesthesia again. CONCLUSIONS Our study suggests that female anaesthetists are generally satisfied with their career choice. However, they are exposed to significant gender-related stresses in the workplace, which are exacerbated by time conflicts for those with children. Allowing part-time employment options and creating a less discriminating environment would enable female doctors to achieve their potential.
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Affiliation(s)
- S V Gardner
- Department of Anaesthesia, Groote Schuur Hospital, University of Cape Town
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