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Huber B, Hammann S, Loeben CE, Jha DK, Vassão DG, Larsen T, Spengler RN, Fuller DQ, Roberts P, Devièse T, Boivin N. Biomolecular characterization of 3500-year-old ancient Egyptian mummification balms from the Valley of the Kings. Sci Rep 2023; 13:12477. [PMID: 37652925 PMCID: PMC10471619 DOI: 10.1038/s41598-023-39393-y] [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: 03/28/2023] [Accepted: 07/25/2023] [Indexed: 09/02/2023] Open
Abstract
Ancient Egyptian mummification was practiced for nearly 4000 years as a key feature of some of the most complex mortuary practices documented in the archaeological record. Embalming, the preservation of the body and organs of the deceased for the afterlife, was a central component of the Egyptian mummification process. Here, we combine GC-MS, HT-GC-MS, and LC-MS/MS analyses to examine mummification balms excavated more than a century ago by Howard Carter from Tomb KV42 in the Valley of the Kings. Balm residues were scraped from now empty canopic jars that once contained the mummified organs of the noble lady Senetnay, dating to the 18th dynasty, ca. 1450 BCE. Our analysis revealed balms consisting of beeswax, plant oil, fats, bitumen, Pinaceae resins, a balsamic substance, and dammar or Pistacia tree resin. These are the richest, most complex balms yet identified for this early time period and they shed light on balm ingredients for which there is limited information in Egyptian textual sources. They highlight both the exceptional status of Senetnay and the myriad trade connections of the Egyptians in the 2nd millennium BCE. They further illustrate the excellent preservation possible even for organic remains long removed from their original archaeological context.
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Affiliation(s)
- B Huber
- Department of Archaeology, Max Planck Institute of Geoanthropology, Jena, Germany.
- Institute for Archaeological Sciences, Eberhard Karl University of Tübingen, Tübingen, Germany.
| | - S Hammann
- Department of Chemistry and Pharmacy, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - C E Loeben
- Egyptian and Islamic Collections, Museum August Kestner, Hannover, Germany
| | - D K Jha
- Department of Archaeology, Max Planck Institute of Geoanthropology, Jena, Germany
| | - D G Vassão
- Department of Archaeology, Max Planck Institute of Geoanthropology, Jena, Germany
- Department of Biochemistry, Max Planck Institute for Chemical Ecology, Jena, Germany
| | - T Larsen
- Department of Archaeology, Max Planck Institute of Geoanthropology, Jena, Germany
| | - R N Spengler
- Department of Archaeology, Max Planck Institute of Geoanthropology, Jena, Germany
- Domestication and Anthropogenic Research Group, Max Planck Institute of Geoanthropology, Jena, Germany
| | - D Q Fuller
- Institute of Archaeology, University College London, London, UK
| | - P Roberts
- Department of Archaeology, Max Planck Institute of Geoanthropology, Jena, Germany
- isoTROPIC Research Group, Max Planck Institute of Geoanthropology, Jena, Germany
| | - T Devièse
- Centre Européen de Recherche et d'Enseignement des Géosciences de l'Environnement (CEREGE), Aix Marseille University, Aix-en-Provence, France
| | - N Boivin
- Department of Archaeology, Max Planck Institute of Geoanthropology, Jena, Germany.
- School of Social Science, The University of Queensland, Brisbane, QLD, Australia.
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Proietti M, Romiti GF, Vitolo M, Harrison SL, Lane DA, Fauchier L, Marin F, Näbauer M, Potpara TS, Dan GA, Maggioni AP, Cesari M, Boriani G, Lip GYH, Ekmekçiu U, Paparisto V, Tase M, Gjergo H, Dragoti J, Goda A, Ciutea M, Ahadi N, el Husseini Z, Raepers M, Leroy J, Haushan P, Jourdan A, Lepiece C, Desteghe L, Vijgen J, Koopman P, Van Genechten G, Heidbuchel H, Boussy T, De Coninck M, Van Eeckhoutte H, Bouckaert N, Friart A, Boreux J, Arend C, Evrard P, Stefan L, Hoffer E, Herzet J, Massoz M, Celentano C, Sprynger M, Pierard L, Melon P, Van Hauwaert B, Kuppens C, Faes D, Van Lier D, Van Dorpe A, Gerardy A, Deceuninck O, Xhaet O, Dormal F, Ballant E, Blommaert D, Yakova D, Hristov M, Yncheva T, Stancheva N, Tisheva S, Tokmakova M, Nikolov F, Gencheva D, Shalganov T, Kunev B, Stoyanov M, Marchov D, Gelev V, Traykov V, Kisheva A, Tsvyatkov H, Shtereva R, Bakalska-Georgieva S, Slavcheva S, Yotov Y, Kubíčková M, Marni Joensen A, Gammelmark A, Hvilsted Rasmussen L, Dinesen P, Riahi S, Krogh Venø S, Sorensen B, Korsgaard A, Andersen K, Fragtrup Hellum C, Svenningsen A, Nyvad O, Wiggers P, May O, Aarup A, Graversen B, Jensen L, Andersen M, Svejgaard M, Vester S, Hansen S, Lynggaard V, Ciudad M, Vettus R, Muda P, Maestre A, Castaño S, Cheggour S, Poulard J, Mouquet V, Leparrée S, Bouet J, Taieb J, Doucy A, Duquenne H, Furber A, Dupuis J, Rautureau J, Font M, Damiano P, Lacrimini M, Abalea J, Boismal S, Menez T, Mansourati J, Range G, Gorka H, Laure C, Vassalière C, Elbaz N, Lellouche N, Djouadi K, Roubille F, Dietz D, Davy J, Granier M, Winum P, Leperchois-Jacquey C, Kassim H, Marijon E, Le Heuzey J, Fedida J, Maupain C, Himbert C, Gandjbakhch E, Hidden-Lucet F, Duthoit G, Badenco N, Chastre T, Waintraub X, Oudihat M, Lacoste J, Stephan C, Bader H, Delarche N, Giry L, Arnaud D, Lopez C, Boury F, Brunello I, Lefèvre M, Mingam R, Haissaguerre M, Le Bidan M, Pavin D, Le Moal V, Leclercq C, Piot O, Beitar T, Martel I, Schmid A, Sadki N, Romeyer-Bouchard C, Da Costa A, Arnault I, Boyer M, Piat C, Fauchier L, Lozance N, Nastevska S, Doneva A, Fortomaroska Milevska B, Sheshoski B, Petroska K, Taneska N, Bakrecheski N, Lazarovska K, Jovevska S, Ristovski V, Antovski A, Lazarova E, Kotlar I, Taleski J, Poposka L, Kedev S, Zlatanovik N, Jordanova S, Bajraktarova Proseva T, Doncovska S, Maisuradze D, Esakia A, Sagirashvili E, Lartsuliani K, Natelashvili N, Gumberidze N, Gvenetadze R, Etsadashvili K, Gotonelia N, Kuridze N, Papiashvili G, Menabde I, Glöggler S, Napp A, Lebherz C, Romero H, Schmitz K, Berger M, Zink M, Köster S, Sachse J, Vonderhagen E, Soiron G, Mischke K, Reith R, Schneider M, Rieker W, Boscher D, Taschareck A, Beer A, Oster D, Ritter O, Adamczewski J, Walter S, Frommhold A, Luckner E, Richter J, Schellner M, Landgraf S, Bartholome S, Naumann R, Schoeler J, Westermeier D, William F, Wilhelm K, Maerkl M, Oekinghaus R, Denart M, Kriete M, Tebbe U, Scheibner T, Gruber M, Gerlach A, Beckendorf C, Anneken L, Arnold M, Lengerer S, Bal Z, Uecker C, Förtsch H, Fechner S, Mages V, Martens E, Methe H, Schmidt T, Schaeffer B, Hoffmann B, Moser J, Heitmann K, Willems S, Willems S, Klaus C, Lange I, Durak M, Esen E, Mibach F, Mibach H, Utech A, Gabelmann M, Stumm R, Ländle V, Gartner C, Goerg C, Kaul N, Messer S, Burkhardt D, Sander C, Orthen R, Kaes S, Baumer A, Dodos F, Barth A, Schaeffer G, Gaertner J, Winkler J, Fahrig A, Aring J, Wenzel I, Steiner S, Kliesch A, Kratz E, Winter K, Schneider P, Haag A, Mutscher I, Bosch R, Taggeselle J, Meixner S, Schnabel A, Shamalla A, Hötz H, Korinth A, Rheinert C, Mehltretter G, Schön B, Schön N, Starflinger A, Englmann E, Baytok G, Laschinger T, Ritscher G, Gerth A, Dechering D, Eckardt L, Kuhlmann M, Proskynitopoulos N, Brunn J, Foth K, Axthelm C, Hohensee H, Eberhard K, Turbanisch S, Hassler N, Koestler A, Stenzel G, Kschiwan D, Schwefer M, Neiner S, Hettwer S, Haeussler-Schuchardt M, Degenhardt R, Sennhenn S, Steiner S, Brendel M, Stoehr A, Widjaja W, Loehndorf S, Logemann A, Hoskamp J, Grundt J, Block M, Ulrych R, Reithmeier A, Panagopoulos V, Martignani C, Bernucci D, Fantecchi E, Diemberger I, Ziacchi M, Biffi M, Cimaglia P, Frisoni J, Boriani G, Giannini I, Boni S, Fumagalli S, Pupo S, Di Chiara A, Mirone P, Fantecchi E, Boriani G, Pesce F, Zoccali C, Malavasi VL, Mussagaliyeva A, Ahyt B, Salihova Z, Koshum-Bayeva K, Kerimkulova A, Bairamukova A, Mirrakhimov E, Lurina B, Zuzans R, Jegere S, Mintale I, Kupics K, Jubele K, Erglis A, Kalejs O, Vanhear K, Burg M, Cachia M, Abela E, Warwicker S, Tabone T, Xuereb R, Asanovic D, Drakalovic D, Vukmirovic M, Pavlovic N, Music L, Bulatovic N, Boskovic A, Uiterwaal H, Bijsterveld N, De Groot J, Neefs J, van den Berg N, Piersma F, Wilde A, Hagens V, Van Es J, Van Opstal J, Van Rennes B, Verheij H, Breukers W, Tjeerdsma G, Nijmeijer R, Wegink D, Binnema R, Said S, Erküner Ö, Philippens S, van Doorn W, Crijns H, Szili-Torok T, Bhagwandien R, Janse P, Muskens A, van Eck M, Gevers R, van der Ven N, Duygun A, Rahel B, Meeder J, Vold A, Holst Hansen C, Engset I, Atar D, Dyduch-Fejklowicz B, Koba E, Cichocka M, Sokal A, Kubicius A, Pruchniewicz E, Kowalik-Sztylc A, Czapla W, Mróz I, Kozlowski M, Pawlowski T, Tendera M, Winiarska-Filipek A, Fidyk A, Slowikowski A, Haberka M, Lachor-Broda M, Biedron M, Gasior Z, Kołodziej M, Janion M, Gorczyca-Michta I, Wozakowska-Kaplon B, Stasiak M, Jakubowski P, Ciurus T, Drozdz J, Simiera M, Zajac P, Wcislo T, Zycinski P, Kasprzak J, Olejnik A, Harc-Dyl E, Miarka J, Pasieka M, Ziemińska-Łuć M, Bujak W, Śliwiński A, Grech A, Morka J, Petrykowska K, Prasał M, Hordyński G, Feusette P, Lipski P, Wester A, Streb W, Romanek J, Woźniak P, Chlebuś M, Szafarz P, Stanik W, Zakrzewski M, Kaźmierczak J, Przybylska A, Skorek E, Błaszczyk H, Stępień M, Szabowski S, Krysiak W, Szymańska M, Karasiński J, Blicharz J, Skura M, Hałas K, Michalczyk L, Orski Z, Krzyżanowski K, Skrobowski A, Zieliński L, Tomaszewska-Kiecana M, Dłużniewski M, Kiliszek M, Peller M, Budnik M, Balsam P, Opolski G, Tymińska A, Ozierański K, Wancerz A, Borowiec A, Majos E, Dabrowski R, Szwed H, Musialik-Lydka A, Leopold-Jadczyk A, Jedrzejczyk-Patej E, Koziel M, Lenarczyk R, Mazurek M, Kalarus Z, Krzemien-Wolska K, Starosta P, Nowalany-Kozielska E, Orzechowska A, Szpot M, Staszel M, Almeida S, Pereira H, Brandão Alves L, Miranda R, Ribeiro L, Costa F, Morgado F, Carmo P, Galvao Santos P, Bernardo R, Adragão P, Ferreira da Silva G, Peres M, Alves M, Leal M, Cordeiro A, Magalhães P, Fontes P, Leão S, Delgado A, Costa A, Marmelo B, Rodrigues B, Moreira D, Santos J, Santos L, Terchet A, Darabantiu D, Mercea S, Turcin Halka V, Pop Moldovan A, Gabor A, Doka B, Catanescu G, Rus H, Oboroceanu L, Bobescu E, Popescu R, Dan A, Buzea A, Daha I, Dan G, Neuhoff I, Baluta M, Ploesteanu R, Dumitrache N, Vintila M, Daraban A, Japie C, Badila E, Tewelde H, Hostiuc M, Frunza S, Tintea E, Bartos D, Ciobanu A, Popescu I, Toma N, Gherghinescu C, Cretu D, Patrascu N, Stoicescu C, Udroiu C, Bicescu G, Vintila V, Vinereanu D, Cinteza M, Rimbas R, Grecu M, Cozma A, Boros F, Ille M, Tica O, Tor R, Corina A, Jeewooth A, Maria B, Georgiana C, Natalia C, Alin D, Dinu-Andrei D, Livia M, Daniela R, Larisa R, Umaar S, Tamara T, Ioachim Popescu M, Nistor D, Sus I, Coborosanu O, Alina-Ramona N, Dan R, Petrescu L, Ionescu G, Popescu I, Vacarescu C, Goanta E, Mangea M, Ionac A, Mornos C, Cozma D, Pescariu S, Solodovnicova E, Soldatova I, Shutova J, Tjuleneva L, Zubova T, Uskov V, Obukhov D, Rusanova G, Soldatova I, Isakova N, Odinsova S, Arhipova T, Kazakevich E, Serdechnaya E, Zavyalova O, Novikova T, Riabaia I, Zhigalov S, Drozdova E, Luchkina I, Monogarova Y, Hegya D, Rodionova L, Rodionova L, Nevzorova V, Soldatova I, Lusanova O, Arandjelovic A, Toncev D, Milanov M, Sekularac N, Zdravkovic M, Hinic S, Dimkovic S, Acimovic T, Saric J, Polovina M, Potpara T, Vujisic-Tesic B, Nedeljkovic M, Zlatar M, Asanin M, Vasic V, Popovic Z, Djikic D, Sipic M, Peric V, Dejanovic B, Milosevic N, Stevanovic A, Andric A, Pencic B, Pavlovic-Kleut M, Celic V, Pavlovic M, Petrovic M, Vuleta M, Petrovic N, Simovic S, Savovic Z, Milanov S, Davidovic G, Iric-Cupic V, Simonovic D, Stojanovic M, Stojanovic S, Mitic V, Ilic V, Petrovic D, Deljanin Ilic M, Ilic S, Stoickov V, Markovic S, Kovacevic S, García Fernandez A, Perez Cabeza A, Anguita M, Tercedor Sanchez L, Mau E, Loayssa J, Ayarra M, Carpintero M, Roldán Rabadan I, Leal M, Gil Ortega M, Tello Montoliu A, Orenes Piñero E, Manzano Fernández S, Marín F, Romero Aniorte A, Veliz Martínez A, Quintana Giner M, Ballesteros G, Palacio M, Alcalde O, García-Bolao I, Bertomeu Gonzalez V, Otero-Raviña F, García Seara J, Gonzalez Juanatey J, Dayal N, Maziarski P, Gentil-Baron P, Shah D, Koç M, Onrat E, Dural IE, Yilmaz K, Özin B, Tan Kurklu S, Atmaca Y, Canpolat U, Tokgozoglu L, Dolu AK, Demirtas B, Sahin D, Ozcan Celebi O, Diker E, Gagirci G, Turk UO, Ari H, Polat N, Toprak N, Sucu M, Akin Serdar O, Taha Alper A, Kepez A, Yuksel Y, Uzunselvi A, Yuksel S, Sahin M, Kayapinar O, Ozcan T, Kaya H, Yilmaz MB, Kutlu M, Demir M, Gibbs C, Kaminskiene S, Bryce M, Skinner A, Belcher G, Hunt J, Stancombe L, Holbrook B, Peters C, Tettersell S, Shantsila A, Lane D, Senoo K, Proietti M, Russell K, Domingos P, Hussain S, Partridge J, Haynes R, Bahadur S, Brown R, McMahon S, Y H Lip G, McDonald J, Balachandran K, Singh R, Garg S, Desai H, Davies K, Goddard W, Galasko G, Rahman I, Chua Y, Payne O, Preston S, Brennan O, Pedley L, Whiteside C, Dickinson C, Brown J, Jones K, Benham L, Brady R, Buchanan L, Ashton A, Crowther H, Fairlamb H, Thornthwaite S, Relph C, McSkeane A, Poultney U, Kelsall N, Rice P, Wilson T, Wrigley M, Kaba R, Patel T, Young E, Law J, Runnett C, Thomas H, McKie H, Fuller J, Pick S, Sharp A, Hunt A, Thorpe K, Hardman C, Cusack E, Adams L, Hough M, Keenan S, Bowring A, Watts J, Zaman J, Goffin K, Nutt H, Beerachee Y, Featherstone J, Mills C, Pearson J, Stephenson L, Grant S, Wilson A, Hawksworth C, Alam I, Robinson M, Ryan S, Egdell R, Gibson E, Holland M, Leonard D, Mishra B, Ahmad S, Randall H, Hill J, Reid L, George M, McKinley S, Brockway L, Milligan W, Sobolewska J, Muir J, Tuckis L, Winstanley L, Jacob P, Kaye S, Morby L, Jan A, Sewell T, Boos C, Wadams B, Cope C, Jefferey P, Andrews N, Getty A, Suttling A, Turner C, Hudson K, Austin R, Howe S, Iqbal R, Gandhi N, Brophy K, Mirza P, Willard E, Collins S, Ndlovu N, Subkovas E, Karthikeyan V, Waggett L, Wood A, Bolger A, Stockport J, Evans L, Harman E, Starling J, Williams L, Saul V, Sinha M, Bell L, Tudgay S, Kemp S, Brown J, Frost L, Ingram T, Loughlin A, Adams C, Adams M, Hurford F, Owen C, Miller C, Donaldson D, Tivenan H, Button H, Nasser A, Jhagra O, Stidolph B, Brown C, Livingstone C, Duffy M, Madgwick P, Roberts P, Greenwood E, Fletcher L, Beveridge M, Earles S, McKenzie D, Beacock D, Dayer M, Seddon M, Greenwell D, Luxton F, Venn F, Mills H, Rewbury J, James K, Roberts K, Tonks L, Felmeden D, Taggu W, Summerhayes A, Hughes D, Sutton J, Felmeden L, Khan M, Walker E, Norris L, O’Donohoe L, Mozid A, Dymond H, Lloyd-Jones H, Saunders G, Simmons D, Coles D, Cotterill D, Beech S, Kidd S, Wrigley B, Petkar S, Smallwood A, Jones R, Radford E, Milgate S, Metherell S, Cottam V, Buckley C, Broadley A, Wood D, Allison J, Rennie K, Balian L, Howard L, Pippard L, Board S, Pitt-Kerby T. Epidemiology and impact of frailty in patients with atrial fibrillation in Europe. Age Ageing 2022; 51:6670566. [PMID: 35997262 DOI: 10.1093/ageing/afac192] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/08/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent. OBJECTIVES We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients. METHODS A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined. RESULTS Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty. CONCLUSIONS In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.
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Affiliation(s)
- Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Translational and Precision Medicine, Sapienza - University of Rome, Italy
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBER-CV, Murcia, Spain
| | - Michael Näbauer
- Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Clinical Center of Serbia, Belgrade, Serbia
| | - Gheorghe-Andrei Dan
- University of Medicine, 'Carol Davila', Colentina University Hospital, Bucharest, Romania
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Matteo Cesari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Kouli O, Murray V, Bhatia S, Cambridge WA, Kawka M, Shafi S, Knight SR, Kamarajah SK, McLean KA, Glasbey JC, Khaw RA, Ahmed W, Akhbari M, Baker D, Borakati A, Mills E, Thavayogan R, Yasin I, Raubenheimer K, Ridley W, Sarrami M, Zhang G, Egoroff N, Pockney P, Richards T, Bhangu A, Creagh-Brown B, Edwards M, Harrison EM, Lee M, Nepogodiev D, Pinkney T, Pearse R, Smart N, Vohra R, Sohrabi C, Jamieson A, Nguyen M, Rahman A, English C, Tincknell L, Kakodkar P, Kwek I, Punjabi N, Burns J, Varghese S, Erotocritou M, McGuckin S, Vayalapra S, Dominguez E, Moneim J, Salehi M, Tan HL, Yoong A, Zhu L, Seale B, Nowinka Z, Patel N, Chrisp B, Harris J, Maleyko I, Muneeb F, Gough M, James CE, Skan O, Chowdhury A, Rebuffa N, Khan H, Down B, Fatimah Hussain Q, Adams M, Bailey A, Cullen G, Fu YXJ, McClement B, Taylor A, Aitken S, Bachelet B, Brousse de Gersigny J, Chang C, Khehra B, Lahoud N, Lee Solano M, Louca M, Rozenbroek P, Rozitis E, Agbinya N, Anderson E, Arwi G, Barry I, Batchelor C, Chong T, Choo LY, Clark L, Daniels M, Goh J, Handa A, Hanna J, Huynh L, Jeon A, Kanbour A, Lee A, Lee J, Lee T, Leigh J, Ly D, McGregor F, Moss J, Nejatian M, O'Loughlin E, Ramos I, Sanchez B, Shrivathsa A, Sincari A, Sobhi S, Swart R, Trimboli J, Wignall P, Bourke E, Chong A, Clayton S, Dawson A, Hardy E, Iqbal R, Le L, Mao S, Marinelli I, Metcalfe H, Panicker D, R HH, Ridgway S, Tan HH, Thong S, Van M, Woon S, Woon-Shoo-Tong XS, Yu S, Ali K, Chee J, Chiu C, Chow YW, Duller A, Nagappan P, Ng S, Selvanathan M, Sheridan C, Temple M, Do JE, Dudi-Venkata NN, Humphries E, Li L, Mansour LT, Massy-Westropp C, Fang B, Farbood K, Hong H, Huang Y, Joan M, Koh C, Liu YHA, Mahajan T, Muller E, Park R, Tanudisastro M, Wu JJG, Chopra P, Giang S, Radcliffe S, Thach P, Wallace D, Wilkes A, Chinta SH, Li J, Phan J, Rahman F, Segaran A, Shannon J, Zhang M, Adams N, Bonte A, Choudhry A, Colterjohn N, Croyle JA, Donohue J, Feighery A, Keane A, McNamara D, Munir K, Roche D, Sabnani R, Seligman D, Sharma S, Stickney Z, Suchy H, Tan R, Yordi S, Ahmed I, Aranha M, El Sabawy D, Garwood P, Harnett M, Holohan R, Howard R, Kayyal Y, Krakoski N, Lupo M, McGilberry W, Nepon H, Scoleri Y, Urbina C, Ahmad Fuad MF, Ahmed O, Jaswantlal D, Kelly E, Khan MHT, Naidu D, Neo WX, O'Neill R, Sugrue M, Abbas JD, Abdul-Fattah S, Azlan A, Barry K, Idris NS, Kaka N, Mc Dermott D, Mohammad Nasir MN, Mozo M, Rehal A, Shaikh Yousef M, Wong RH, Curran E, Gardner M, Hogan A, Julka R, Lasser G, Ní Chorráin N, Ting J, Browne R, George S, Janjua Z, Leung Shing V, Megally M, Murphy S, Ravenscroft L, Vedadi A, Vyas V, Bryan A, Sheikh A, Ubhi J, Vannelli K, Vawda A, Adeusi L, Doherty C, Fitzgerald C, Gallagher H, Gill P, Hamza H, Hogan M, Kelly S, Larry J, Lynch P, Mazeni NA, O'Connell R, O'Loghlin R, Singh K, Abbas Syed R, Ali A, Alkandari B, Arnold A, Arora E, Azam R, Breathnach C, Cheema J, Compton M, Curran S, Elliott JA, Jayasamraj O, Mohammed N, Noone A, Pal A, Pandey S, Quinn P, Sheridan R, Siew L, Tan EP, Tio SW, Toh VTR, Walsh M, Yap C, Yassa J, Young T, Agarwal N, Almoosawy SA, Bowen K, Bruce D, Connachan R, Cook A, Daniell A, Elliott M, Fung HKF, Irving A, Laurie S, Lee YJ, Lim ZX, Maddineni S, McClenaghan RE, Muthuganesan V, Ravichandran P, Roberts N, Shaji S, Solt S, Toshney E, Arnold C, Baker O, Belais F, Bojanic C, Byrne M, Chau CYC, De Soysa S, Eldridge M, Fairey M, Fearnhead N, Guéroult A, Ho JSY, Joshi K, Kadiyala N, Khalid S, Khan F, Kumar K, Lewis E, Magee J, Manetta-Jones D, Mann S, McKeown L, Mitrofan C, Mohamed T, Monnickendam A, Ng AYKC, Ortu A, Patel M, Pope T, Pressling S, Purohit K, Saji S, Shah Foridi J, Shah R, Siddiqui SS, Surman K, Utukuri M, Varghese A, Williams CYK, Yang JJ, Billson E, Cheah E, Holmes P, Hussain S, Murdock D, Nicholls A, Patel P, Ramana G, Saleki M, Spence H, Thomas D, Yu C, Abousamra M, Brown C, Conti I, Donnelly A, Durand M, French N, Goan R, O'Kane E, Rubinchik P, Gardiner H, Kempf B, Lai YL, Matthews H, Minford E, Rafferty C, Reid C, Sheridan N, Al Bahri T, Bhoombla N, Rao BM, Titu L, Chatha S, Field C, Gandhi T, Gulati R, Jha R, Jones Sam MT, Karim S, Patel R, Saunders M, Sharma K, Abid S, Heath E, Kurup D, Patel A, Ali M, Cresswell B, Felstead D, Jennings K, Kaluarachchi T, Lazzereschi L, Mayson H, Miah JE, Reinders B, Rosser A, Thomas C, Williams H, Al-Hamid Z, Alsadoun L, Chlubek M, Fernando P, Gaunt E, Gercek Y, Maniar R, Ma R, Matson M, Moore S, Morris A, Nagappan PG, Ratnayake M, Rockall L, Shallcross O, Sinha A, Tan KE, Virdee S, Wenlock R, Donnelly HA, Ghazal R, Hughes I, Liu X, McFadden M, Misbert E, Mogey P, O'Hara A, Peace C, Rainey C, Raja P, Salem M, Salmon J, Tan CH, Alves D, Bahl S, Baker C, Coulthurst J, Koysombat K, Linn T, Rai P, Sharma A, Shergill A, Ahmed M, Ahmed S, Belk LH, Choudhry H, Cummings D, Dixon Y, Dobinson C, Edwards J, Flint J, Franco Da Silva C, Gallie R, Gardener M, Glover T, Greasley M, Hatab A, Howells R, Hussey T, Khan A, Mann A, Morrison H, Ng A, Osmond R, Padmakumar N, Pervaiz F, Prince R, Qureshi A, Sawhney R, Sigurdson B, Stephenson L, Vora K, Zacken A, Cope P, Di Traglia R, Ferarrio I, Hackett N, Healicon R, Horseman L, Lam LI, Meerdink M, Menham D, Murphy R, Nimmo I, Ramaesh A, Rees J, Soame R, Dilaver N, Adebambo D, Brown E, Burt J, Foster K, Kaliyappan L, Knight P, Politis A, Richardson E, Townsend J, Abdi M, Ball M, Easby S, Gill N, Ho E, Iqbal H, Matthews M, Nubi S, Nwokocha JO, Okafor I, Perry G, Sinartio B, Vanukuru N, Walkley D, Welch T, Yates J, Yeshitila N, Bryans K, Campbell B, Gray C, Keys R, Macartney M, Chamberlain G, Khatri A, Kucheria A, Lee STP, Reese G, Roy choudhury J, Tan WYR, Teh JJ, Ting A, Kazi S, Kontovounisios C, Vutipongsatorn K, Amarnath T, Balasubramanian N, Bassett E, Gurung P, Lim J, Panjikkaran A, Sanalla A, Alkoot M, Bacigalupo V, Eardley N, Horton M, Hurry A, Isti C, Maskell P, Nursiah K, Punn G, Salih H, Epanomeritakis E, Foulkes A, Henderson R, Johnston E, McCullough H, McLarnon M, Morrison E, Cheung A, Cho SH, Eriksson F, Hedges J, Low Z, May C, Musto L, Nagi S, Nur S, Salau E, Shabbir S, Thomas MC, Uthayanan L, Vig S, Zaheer M, Zeng G, Ashcroft-Quinn S, Brown R, Hayes J, McConville R, French R, Gilliam A, Sheetal S, Shehzad MU, Bani W, Christie I, Franklyn J, Khan M, Russell J, Smolarek S, Varadarassou R, Ahmed SK, Narayanaswamy S, Sealy J, Shah M, Dodhia V, Manukyan A, O'Hare R, Orbell J, Chung I, Forenc K, Gupta A, Agarwal A, Al Dabbagh A, Bennewith R, Bottomley J, Chu TSM, Chu YYA, Doherty W, Evans B, Hainsworth P, Hosfield T, Li CH, McCullagh I, Mehta A, Thaker A, Thompson B, Virdi A, Walker H, Wilkins E, Dixon C, Hassan MR, Lotca N, Tong KS, Batchelor-Parry H, Chaudhari S, Harris T, Hooper J, Johnson C, Mulvihill C, Nayler J, Olutobi O, Piramanayagam B, Stones K, Sussman M, Weaver C, Alam F, Al Rawi M, Andrew F, Arrayeh A, Azizan N, Hassan A, Iqbal Z, John I, Jones M, Kalake O, Keast M, Nicholas J, Patil A, Powell K, Roberts P, Sabri A, Segue AK, Shah A, Shaik Mohamed SA, Shehadeh A, Shenoy S, Tong A, Upcott M, Vijayasingam D, Anarfi S, Dauncey J, Devindaran A, Havalda P, Komninos G, Mwendwa E, Norman C, Richards J, Urquhart A, Allan J, Cahya E, Hunt H, McWhirter C, Norton R, Roxburgh C, Tan JY, Ali Butt S, Hansdot S, Haq I, Mootien A, Sanchez I, Vainas T, Deliyannis E, Tan M, Vipond M, Chittoor Satish NN, Dattani A, De Carvalho L, Gaston-Grubb M, Karunanithy L, Lowe B, Pace C, Raju K, Roope J, Taylor C, Youssef H, Munro T, Thorn C, Wong KHF, Yunus A, Chawla S, Datta A, Dinesh AA, Field D, Georgi T, Gwozdz A, Hamstead E, Howard N, Isleyen N, Jackson N, Kingdon J, Sagoo KS, Schizas A, Yin L, Aung E, Aung YY, Franklin S, Han SM, Kim WC, Martin Segura A, Rossi M, Ross T, Tirimanna R, Wang B, Zakieh O, Ben-Arzi H, Flach A, Jackson E, Magers S, Olu abara C, Rogers E, Sugden K, Tan H, Veliah S, Walton U, Asif A, Bharwada Y, Bowley D, Broekhuizen A, Cooper L, Evans N, Girdlestone H, Ling C, Mann H, Mehmood N, Mulvenna CL, Rainer N, Trout I, Gujjuri R, Jeyaraman D, Leong E, Singh D, Smith E, Anderton J, Barabas M, Goyal S, Howard D, Joshi A, Mitchell D, Weatherby T, Badminton R, Bird R, Burtle D, Choi NY, Devalia K, Farr E, Fischer F, Fish J, Gunn F, Jacobs D, Johnston P, Kalakoutas A, Lau E, Loo YNAF, Louden H, Makariou N, Mohammadi K, Nayab Y, Ruhomaun S, Ryliskyte R, Saeed M, Shinde P, Sudul M, Theodoropoulou K, Valadao-Spoorenberg J, Vlachou F, Arshad SR, Janmohamed AM, Noor M, Oyerinde O, Saha A, Syed Y, Watkinson W, Ahmadi H, Akintunde A, Alsaady A, Bradley J, Brothwood D, Burton M, Higgs M, Hoyle C, Katsura C, Lathan R, Louani A, Mandalia R, Prihartadi AS, Qaddoura B, Sandland-Taylor L, Thadani S, Thompson A, Walshaw J, Teo S, Ali S, Bawa JH, Fox S, Gargan K, Haider SA, Hanna N, Hatoum A, Khan Z, Krzak AM, Li T, Pitt J, Tan GJS, Ullah Z, Wilson E, Cleaver J, Colman J, Copeland L, Coulson A, Davis P, Faisal H, Hassan F, Hughes JT, Jabr Y, Mahmoud Ali F, Nahaboo Solim ZN, Sangheli A, Shaya S, Thompson R, Cornwall H, De Andres Crespo M, Fay E, Findlay J, Groves E, Jones O, Killen A, Millo J, Thomas S, Ward J, Wilkins M, Zaki F, Zilber E, Bhavra K, Bilolikar A, Charalambous M, Elawad A, Eleni A, Fawdon R, Gibbins A, Livingstone D, Mala D, Oke SE, Padmakumar D, Patsalides MA, Payne D, Ralphs C, Roney A, Sardar N, Stefanova K, Surti F, Timms R, Tosney G, Bannister J, Clement NS, Cullimore V, Kamal F, Lendor J, McKay J, Mcswiggan J, Minhas N, Seneviratne K, Simeen S, Valverde J, Watson N, Bloom I, Dinh TH, Hirniak J, Joseph R, Kansagra M, Lai CKN, Melamed N, Patel J, Randev J, Sedighi T, Shurovi B, Sodhi J, Vadgama N, Abdulla S, Adabavazeh B, Champion A, Chennupati R, Chu K, Devi S, Haji A, Schulz J, Testa F, Davies P, Gurung B, Howell S, Modi P, Pervaiz A, Zahid M, Abdolrazaghi S, Abi Aoun R, Anjum Z, Bawa G, Bhardwaj R, Brown S, Enver M, Gill D, Gopikrishna D, Gurung D, Kanwal A, Kaushal P, Khanna A, Lovell E, McEvoy C, Mirza M, Nabeel S, Naseem S, Pandya K, Perkins R, Pulakal R, Ray M, Reay C, Reilly S, Round A, Seehra J, Shakeel NM, Singh B, Vijay Sukhnani M, Brown L, Desai B, Elzanati H, Godhaniya J, Kavanagh E, Kent J, Kishor A, Liu A, Norwood M, Shaari N, Wood C, Wood M, Brown A, Chellapuri A, Ferriman A, Ghosh I, Kulkarni N, Noton T, Pinto A, Rajesh S, Varghese B, Wenban C, Aly R, Barciela C, Brookes T, Corrin E, Goldsworthy M, Mohamed Azhar MS, Moore J, Nakhuda S, Ng D, Pillay S, Port S, Abdullah M, Akinyemi J, Islam S, Kale A, Lewis A, Manjunath T, McCabe H, Misra S, Stubley T, Tam JP, Waraich N, Chaora T, Ford C, Osinkolu I, Pong G, Rai J, Risquet R, Ainsworth J, Ayandokun P, Barham E, Barrett G, Barry J, Bisson E, Bridges I, Burke D, Cann J, Cloney M, Coates S, Cripps P, Davies C, Francis N, Green S, Handley G, Hathaway D, Hurt L, Jenkins S, Johnston C, Khadka A, McGee U, Morris D, Murray R, Norbury C, Pierrepont Z, Richards C, Ross O, Ruddy A, Salmon C, Shield M, Soanes K, Spencer N, Taverner S, Williams C, Wills-Wood W, Woodward S, Chow J, Fan J, Guest O, Hunter I, Moon WY, Arthur-Quarm S, Edwards P, Hamlyn V, McEneaney L, N D G, Pranoy S, Ting M, Abada S, Alawattegama LH, Ashok A, Carey C, Gogna A, Haglund C, Hurley P, Leelo N, Liu B, Mannan F, Paramjothy K, Ramlogan K, Raymond-Hayling O, Shanmugarajah A, Solichan D, Wilkinson B, Ahmad NA, Allan D, Amin A, Bakina C, Burns F, Cameron F, Campbell A, Cavanagh S, Chan SMZ, Chapman S, Chong V, Edelsten E, Ekpete O, El Sheikh M, Ghose R, Hassane A, Henderson C, Hilton-Christie S, Husain M, Hussain H, Javid Z, Johnson-Ogbuneke J, Johnston A, Khalil M, Leung TCC, Makin I, Muralidharan V, Naeem M, Patil P, Ravichandran S, Saraeva D, Shankey-Smith W, Sharma N, Swan R, Waudby-West R, Wilkinson A, Wright K, Balasubramanian A, Bhatti S, Chalkley M, Chou WK, Dixon M, Evans L, Fisher K, Gandhi P, Ho S, Lau YB, Lowe S, Meechan C, Murali N, Musonda C, Njoku P, Ochieng L, Pervez MU, Seebah K, Shaikh I, Sikder MA, Vanker R, Alom J, Bajaj V, Coleman O, Finch G, Goss J, Jenkins C, Kontothanassis A, Liew MS, Ng K, Outram M, Shakeel MM, Tawn J, Zuhairy S, Chapple K, Cinnamond A, Coleman S, George HA, Goulder L, Hare N, Hawksley J, Kret A, Luesley A, Mecia L, Porter H, Puddy E, Richardson G, Sohail B, Srikaran V, Tadross D, Tobin J, Tokidis E, Young L, Ashdown T, Bratsos S, Koomson A, Kufuor A, Lim MQ, Shah S, Thorne EPC, Warusavitarne J, Xu S, Abigail S, Ahmed A, Ahmed J, Akmal A, Al-Khafaji M, Amini B, Arshad M, Bogie E, Brazkiewicz M, Carroll M, Chandegra A, Cirelli C, Deng A, Fairclough S, Fung YJ, Gornell C, Green RL, Green SV, Gulamhussein AHM, Isaac AG, Jan R, Jegatheeswaran L, Knee M, Kotecha J, Kotecha S, Maxwell-Armstrong C, McIntyre C, Mendis N, Naing TKP, Oberman J, Ong ZX, Ramalingam A, Saeed Adam A, Tan LL, Towell S, Yadav J, Anandampillai R, Chung S, Hounat A, Ibrahim B, Jeyakumar G, Khalil A, Khan UA, Nair G, Owusu-Ayim M, Wilson M, Kanani A, Kilkelly B, Ogunmwonyi I, Ong L, Samra B, Schomerus L, Shea J, Turner O, Yang Y, Amin M, Blott N, Clark A, Feather A, Forrest M, Hague S, Hamilton K, Higginbotham G, Hope E, Karimian S, Loveday K, Malik H, McKenna O, Noor A, Onsiong C, Patel B, Radcliffe N, Shah P, Tye L, Verma K, Walford R, Yusufi U, Zachariah M, Casey A, Doré C, Fludder V, Fortescue L, Kalapu SS, Karel E, Khera G, Smith C, Appleton B, Ashaye A, Boggon E, Evans A, Faris Mahmood H, Hinchcliffe Z, Marei O, Silva I, Spooner C, Thomas G, Timlin M, Wellington J, Yao SL, Abdelrazek M, Abdelrazik Y, Bee F, Joseph A, Mounce A, Parry G, Vignarajah N, Biddles D, Creissen A, Kolhe S, K T, Lea A, Ledda V, O'Loughlin P, Scanlon J, Shetty N, Weller C, Abdalla M, Adeoye A, Bhatti M, Chadda KR, Chu J, Elhakim H, Foster-Davies H, Rabie M, Tailor B, Webb S, Abdelrahim ASA, Choo SY, Jiwa A, Mangam S, Murray S, Shandramohan A, Aghanenu O, Budd W, Hayre J, Khanom S, Liew ZY, McKinney R, Moody N, Muhammad-Kamal H, Odogwu J, Patel D, Roy C, Sattar Z, Shahrokhi N, Sinha I, Thomson E, Wonga L, Bain J, Khan J, Ricardo D, Bevis R, Cherry C, Darkwa S, Drew W, Griffiths E, Konda N, Madani D, Mak JKC, Meda B, Odunukwe U, Preest G, Raheel F, Rajaseharan A, Ramgopal A, Risbrooke C, Selvaratnam K, Sethunath G, Tabassum R, Taylor J, Thakker A, Wijesingha N, Wybrew R, Yasin T, Ahmed Osman A, Alfadhel S, Carberry E, Chen JY, Drake I, Glen P, Jayasuriya N, Kawar L, Myatt R, Sinan LOH, Siu SSY, Tjen V, Adeboyejo O, Bacon H, Barnes R, Birnie C, D'Cunha Kamath A, Hughes E, Middleton S, Owen R, Schofield E, Short C, Smith R, Wang H, Willett M, Zimmerman M, Balfour J, Chadwick T, Coombe-Jones M, Do Le HP, Faulkner G, Hobson K, Shehata Z, Beattie M, Chmielewski G, Chong C, Donnelly B, Drusch B, Ellis J, Farrelly C, Feyi-Waboso J, Hibell I, Hoade L, Ho C, Jones H, Kodiatt B, Lidder P, Ni Cheallaigh L, Norman R, Patabendi I, Penfold H, Playfair M, Pomeroy S, Ralph C, Rottenburg H, Sebastian J, Sheehan M, Stanley V, Welchman J, Ajdarpasic D, Antypas A, Azouaghe O, Basi S, Bettoli G, Bhattarai S, Bommireddy L, Bourne K, Budding J, Cookey-Bresi R, Cummins T, Davies G, Fabelurin C, Gwilliam R, Hanley J, Hird A, Kruczynska A, Langhorne B, Lund J, Lutchman I, McGuinness R, Neary M, Pampapathi S, Pang E, Podbicanin S, Rai N, Redhouse White G, Sujith J, Thomas P, Walker I, Winterton R, Anderson P, Barrington M, Bhadra K, Clark G, Fowler G, Gibson C, Hudson S, Kaminskaite V, Lawday S, Longshaw A, MacKrill E, McLachlan F, Murdeshwar A, Nieuwoudt R, Parker P, Randall R, Rawlins E, Reeves SA, Rye D, Sirkis T, Sykes B, Ventress N, Wosinska N, Akram B, Burton L, Coombs A, Long R, Magowan D, Ong C, Sethi M, Williams G, Chan C, Chan LH, Fernando D, Gaba F, Khor Z, Les JW, Mak R, Moin S, Ng Kee Kwong KC, Paterson-Brown S, Tew YY, Bardon A, Burrell K, Coldwell C, Costa I, Dexter E, Hardy A, Khojani M, Mazurek J, Raymond T, Reddy V, Reynolds J, Soma A, Agiotakis S, Alsusa H, Desai N, Peristerakis I, Adcock A, Ayub H, Bennett T, Bibi F, Brenac S, Chapman T, Clarke G, Clark F, Galvin C, Gwyn-Jones A, Henry-Blake C, Kerner S, Kiandee M, Lovett A, Pilecka A, Ravindran R, Siddique H, Sikand T, Treadwell K, Akmal K, Apata A, Barton O, Broad G, Darling H, Dhuga Y, Emms L, Habib S, Jain R, Jeater J, Kan CYP, Kathiravelupillai A, Khatkar H, Kirmani S, Kulasabanathan K, Lacey H, Lal K, Manafa C, Mansoor M, McDonald S, Mittal A, Mustoe S, Nottrodt L, Oliver P, Papapetrou I, Pattinson F, Raja M, Reyhani H, Shahmiri A, Small O, Soni U, Aguirrezabala Armbruster B, Bunni J, Hakim MA, Hawkins-Hooker L, Howell KA, Hullait R, Jaskowska A, Ottewell L, Thomas-Jones I, Vasudev A, Clements B, Fenton J, Gill M, Haider S, Lim AJM, Maguire H, McMullan J, Nicoletti J, Samuel S, Unais MA, White N, Yao PC, Yow L, Boyle C, Brady R, Cheekoty P, Cheong J, Chew SJHL, Chow R, Ganewatta Kankanamge D, Mamer L, Mohammed B, Ng Chieng Hin J, Renji Chungath R, Royston A, Sharrad E, Sinclair R, Tingle S, Treherne K, Wyatt F, Maniarasu VS, Moug S, Appanna T, Bucknall T, Hussain F, Owen A, Parry M, Parry R, Sagua N, Spofforth K, Yuen ECT, Bosley N, Hardie W, Moore T, Regas C, Abdel-Khaleq S, Ali N, Bashiti H, Buxton-Hopley R, Constantinides M, D'Afflitto M, Deshpande A, Duque Golding J, Frisira E, Germani Batacchi M, Gomaa A, Hay D, Hutchison R, Iakovou A, Iakovou D, Ismail E, Jefferson S, Jones L, Khouli Y, Knowles C, Mason J, McCaughan R, Moffatt J, Morawala A, Nadir H, Neyroud F, Nikookam Y, Parmar A, Pinto L, Ramamoorthy R, Richards E, Thomson S, Trainer C, Valetopoulou A, Vassiliou A, Wantman A, Wilde S, Dickinson M, Rockall T, Senn D, Wcislo K, Zalmay P, Adelekan K, Allen K, Bajaj M, Gatumbu P, Hang S, Hashmi Y, Kaur T, Kawesha A, Kisiel A, Woodmass M, Adelowo T, Ahari D, Alhwaishel K, Atherton R, Clayton B, Cockroft A, Curtis Lopez C, Hilton M, Ismail N, Kouadria M, Lee L, MacConnachie A, Monks F, Mungroo S, Nikoletopoulou C, Pearce L, Sara X, Shahid A, Suresh G, Wilcha R, Atiyah A, Davies E, Dermanis A, Gibbons H, Hyde A, Lawson A, Lee C, Leung-Tack M, Li Saw Hee J, Mostafa O, Nair D, Pattani N, Plumbley-Jones J, Pufal K, Ramesh P, Sanghera J, Saram S, Scadding S, See S, Stringer H, Torrance A, Vardon H, Wyn-Griffiths F, Brew A, Kaur G, Soni D, Tickle A, Akbar Z, Appleyard T, Figg K, Jayawardena P, Johnson A, Kamran Siddiqui Z, Lacy-Colson J, Oatham R, Rowlands B, Sludden E, Turnbull C, Allin D, Ansar Z, Azeez Z, Dale VH, Garg J, Horner A, Jones S, Knight S, McGregor C, McKenna J, McLelland T, Packham-Smith A, Rowsell K, Spector-Hill I, Adeniken E, Baker J, Bartlett M, Chikomba L, Connell B, Deekonda P, Dhar M, Elmansouri A, Gamage K, Goodhew R, Hanna P, Knight J, Luca A, Maasoumi N, Mahamoud F, Manji S, Marwaha PK, Mason F, Oluboyede A, Pigott L, Razaq AM, Richardson M, Saddaoui I, Wijeyendram P, Yau S, Atkins W, Liang K, Miles N, Praveen B, Ashai S, Braganza J, Common J, Cundy A, Davies R, Guthrie J, Handa I, Iqbal M, Ismail R, Jones C, Jones I, Lee KS, Levene A, Okocha M, Olivier J, Smith A, Subramaniam E, Tandle S, Wang A, Watson A, Wilson C, Chan XHF, Khoo E, Montgomery C, Norris M, Pugalenthi PP, Common T, Cook E, Mistry H, Shinmar HS, Agarwal G, Bandyopadhyay S, Brazier B, Carroll L, Goede A, Harbourne A, Lakhani A, Lami M, Larwood J, Martin J, Merchant J, Pattenden S, Pradhan A, Raafat N, Rothwell E, Shammoon Y, Sudarshan R, Vickers E, Wingfield L, Ashworth I, Azizi S, Bhate R, Chowdhury T, Christou A, Davies L, Dwaraknath M, Farah Y, Garner J, Gureviciute E, Hart E, Jain A, Javid S, Kankam HK, Kaur Toor P, Kaz R, Kermali M, Khan I, Mattson A, McManus A, Murphy M, Nair K, Ngemoh D, Norton E, Olabiran A, Parry L, Payne T, Pillai K, Price S, Punjabi K, Raghunathan A, Ramwell A, Raza M, Ritehnia J, Simpson G, Smith W, Sodeinde S, Studd L, Subramaniam M, Thomas J, Towey S, Tsang E, Tuteja D, Vasani J, Vio M, Badran A, Adams J, Anthony Wilkinson J, Asvandi S, Austin T, Bald A, Bix E, Carrick M, Chander B, Chowdhury S, Cooper Drake B, Crosbie S, D Portela S, Francis D, Gallagher C, Gillespie R, Gravett H, Gupta P, Ilyas C, James G, Johny J, Jones A, Kinder F, MacLeod C, Macrow C, Maqsood-Shah A, Mather J, McCann L, McMahon R, Mitham E, Mohamed M, Munton E, Nightingale K, O'Neill K, Onyemuchara I, Senior R, Shanahan A, Sherlock J, Spyridoulias A, Stavrou C, Stokes D, Tamang R, Taylor E, Trafford C, Uden C, Waddington C, Yassin D, Zaman M, Bangi S, Cheng T, Chew D, Hussain N, Imani-Masouleh S, Mahasivam G, McKnight G, Ng HL, Ota HC, Pasha T, Ravindran W, Shah K, Vishnu K S, Zaman S, Carr W, Cope S, Eagles EJ, Howarth-Maddison M, Li CY, Reed J, Ridge A, Stubbs T, Teasdaled D, Umar R, Worthington J, Dhebri A, Kalenderov R, Alattas A, Arain Z, Bhudia R, Chia D, Daniel S, Dar T, Garland H, Girish M, Hampson A, Kyriacou H, Lehovsky K, Mullins W, Omorphos N, Vasdev N, Venkatesh A, Waldock W, Bhandari A, Brown G, Choa G, Eichenauer CE, Ezennia K, Kidwai Z, Lloyd-Thomas A, Macaskill Stewart A, Massardi C, Sinclair E, Skajaa N, Smith M, Tan I, Afsheen N, Anuar A, Azam Z, Bhatia P, Davies-kelly N, Dickinson S, Elkawafi M, Ganapathy M, Gupta S, Khoury EG, Licudi D, Mehta V, Neequaye S, Nita G, Tay VL, Zhao S, Botsa E, Cuthbert H, Elliott J, Furlepa M, Lehmann J, Mangtani A, Narayan A, Nazarian S, Parmar C, Shah D, Shaw C, Zhao Z, Beck C, Caldwell S, Clements JM, French B, Kenny R, Kirk S, Lindsay J, McClung A, McLaughlin N, Watson S, Whiteside E, Alyacoubi S, Arumugam V, Beg R, Dawas K, Garg S, Lloyd ER, Mahfouz Y, Manobharath N, Moonesinghe R, Morka N, Patel K, Prashar J, Yip S, Adeeko ES, Ajekigbe F, Bhat A, Evans C, Farrugia A, Gurung C, Long T, Malik B, Manirajan S, Newport D, Rayer J, Ridha A, Ross E, Saran T, Sinker A, Waruingi D, Allen R, Al Sadek Y, Alves do Canto Brum H, Asharaf H, Ashman M, Balakumar V, Barrington J, Baskaran R, Berry A, Bhachoo H, Bilal A, Boaden L, Chia WL, Covell G, Crook D, Dadnam F, Davis L, De Berker H, Doyle C, Fox C, Gruffydd-Davies M, Hafouda Y, Hill A, Hubbard E, Hunter A, Inpadhas V, Jamshaid M, Jandu G, Jeyanthi M, Jones T, Kantor C, Kwak SY, Malik N, Matt R, McNulty P, Miles C, Mohomed A, Myat P, Niharika J, Nixon A, O'Reilly D, Parmar K, Pengelly S, Price L, Ramsden M, Turnor R, Wales E, Waring H, Wu M, Yang T, Ye TTS, Zander A, Zeicu C, Bellam S, Francombe J, Kawamoto N, Rahman MR, Sathyanarayana A, Tang HT, Cheung J, Hollingshead J, Page V, Sugarman J, Wong E, Chiong J, Fung E, Kan SY, Kiang J, Kok J, Krahelski O, Liew MY, Lyell B, Sharif Z, Speake D, Alim L, Amakye NY, Chandrasekaran J, Chandratreya N, Drake J, Owoso T, Thu YM, Abou El Ela Bourquin B, Alberts J, Chapman D, Rehnnuma N, Ainsworth K, Carpenter H, Emmanuel T, Fisher T, Gabrel M, Guan Z, Hollows S, Hotouras A, Ip Fung Chun N, Jaffer S, Kallikas G, Kennedy N, Lewinsohn B, Liu FY, Mohammed S, Rutherfurd A, Situ T, Stammer A, Taylor F, Thin N, Urgesi E, Zhang N, Ahmad MA, Bishop A, Bowes A, Dixit A, Glasson R, Hatta S, Hatt K, Larcombe S, Preece J, Riordan E, Fegredo D, Haq MZ, Li C, McCann G, Stewart D, Baraza W, Bhullar D, Burt G, Coyle J, Deans J, Devine A, Hird R, Ikotun O, Manchip G, Ross C, Storey L, Tan WWL, Tse C, Warner C, Whitehead M, Wu F, Court EL, Crisp E, Huttman M, Mayes F, Robertson H, Rosen H, Sandberg C, Smith H, Al Bakry M, Ashwell W, Bajaj S, Bandyopadhyay D, Browlee O, Burway S, Chand CP, Elsayeh K, Elsharkawi A, Evans E, Ferrin S, Fort-Schaale A, Iacob M, I K, Impelliziere Licastro G, Mankoo AS, Olaniyan T, Otun J, Pereira R, Reddy R, Saeed D, Simmonds O, Singhal G, Tron K, Wickstone C, Williams R, Bradshaw E, De Kock Jewell V, Houlden C, Knight C, Metezai H, Mirza-Davies A, Seymour Z, Spink D, Wischhusen S. Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study. Lancet Digit Health 2022; 4:e520-e531. [PMID: 35750401 DOI: 10.1016/s2589-7500(22)00069-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/07/2022] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. METHODS We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). FINDINGS In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]). INTERPRETATION In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. FUNDING British Journal of Surgery Society.
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Elrefai M, Abouelasaad M, Dunn A, Coniglio S, Zemkoho A, Wiles B, Roberts P. Eligibility for subcutaneous implantable cardiac defibrillator utilising artificial intelligence and deep learning methods for prolonged screening: where is the cut-off? Europace 2022. [DOI: 10.1093/europace/euac053.447] [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: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Main author is receiving an unrestricted grant by Boston Scientific
Background
S-ICD eligibility is determined by a single surface ECG analysis in which the suitability of an individual’s ECG vector morphology is assessed. A major predictor of eligibility is the T:R ratio. Current screening tools proposes T: R of 1:3 as a cut-off for eligibility. Inappropriate shocks due to T-wave oversensing (TWO) remains an issue despite screening. EFFORTLESS and PRAETORIAN trials reported inappropriate shock rates of 11.4% and 9.7% respectively, most frequently caused by cardiac oversensing.
Purpose
The cut-off T: R of 1:3 currently used incorporates a safety margin to accommodate for ECG signal amplitudes fluctuations without affecting S-ICD sensing. Prolonged screening using our tool accurately measures the T: R fluctuations. However, utilising a T: R of 1:3 for prolonged screening can unnecessarily exclude appropriate S-ICD candidates. The purpose of our study is to provide groundwork for future trials to find the optimal ratio that identifies patients at risk of TWO and inappropriate shocks while not excluding true S-ICD candidates after prolonged screening.
Methods
Patients were fitted with 24-hour Holter monitors with leads placed to correspond to the vectors of an S-ICD. We used our tool to assess T: R over the recordings utilising Phase Space Reconstruction matrices - to convert the ECG signal into compressed pixel images. A Convolutional Neural Network (CNN) model was trained to accurately predict the T: R from these images resulting in a T: R variation plot for each vector. We then applied multiple T:R ratio cut-offs on the recordings to identify patients at risk of inappropriate shocks due to TWO at each proposed value. A vector with a T: R above the cut-off for 20 consecutive seconds was deemed to have failed screening, the time determined by the current detection, charge, and redetection time of the current S-ICD system. A patient has to have at least one suitable vector to pass the screening at the selected threshold.
Results
37 patients (mean age 54.5 years,64.8% male) were included. 14 had Heart failure, 7 Hypertrophic cardiomyopathy, 7 normal hearts, 6 Adult congenital heart disease and 3 patients who received inappropriate S-ICD shocks due to TWO. Overall, 20 (54%) of patients passed prolonged screening using a 1:3 ratio. All of the patients passed screening with a T: R of 1:1. The only subgroup to wholly pass the screening for all the proposed ratios are the normal hearts group.
Conclusion
We propose adopting prolonged screening to select S-ICD eligible patients with low probability of TWO and inappropriate shocks. However, utilising T: R of 1:3 can unnecessarily exclude otherwise S-ICD eligible patients. The appropriate ratio likely lies between 1:3 - 1:1. Further studies are needed to identify the optimal screening thresholds, particularly in patients that have had inappropriate shocks due to TWO.
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Affiliation(s)
- M Elrefai
- University of Southampton, School of Medicine, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - M Abouelasaad
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - A Dunn
- University of Southampton, School of Maths, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - S Coniglio
- University of Southampton, School of Maths, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - A Zemkoho
- University of Southampton, School of Maths, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - B Wiles
- King’s College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - P Roberts
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
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Elrefai M, Abouelasaad M, Nettey D, Roberts P. A leadless pacemaker matched with a vasovagal syncope: how long can it last? Europace 2022. [DOI: 10.1093/europace/euac053.319] [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: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): Dr.Mohamed ElRefai is receiving an unrestricted grant from Boston Scientific
Introduction
Although a benign condition, patients suffering from frequent vasovagal syncopal episodes need treatment to improve their quality of life. ESC Guidelines consider pacing for patients >40 years old with documented symptomatic asystolic pauses >3 seconds or asymptomatic pauses >6 seconds. Caution is advised with use of pacing in younger patients, due to long-term complications associated with transvenous pacemakers (TV-PPM). The ESC guidelines recommend that Leadless pacemakers (LP) should be considered as an alternative to TV-PPM when there is no appropriate venous access or if the risk of device infection is high, also on a case-by-case basis using shared decision making.
Studies on the use of LPs for cardioinhibitory vasovagal population specifically, concluded that the safety and efficacy of LPs are comparable with TV-PPM, demonstrating a high level of symptom improvement at follow up making them a reasonable option in these patients. In addition, observational studies demonstrated that LPs are associated with better quality of life than TV-PPM.
Purpose
Current practice is to implant another LP after the end of life of the old device without extracting it. There are concerns regards battery longevity specially with the paucity of data on device extraction and the number of concomitant LPs that can be implanted safely, a concern in younger patients’ population potentially requiring decades of pacing therapy. We aim to evaluate the performance of the LPs in the relatively younger vasovagal syncope patients with anticipated very low pacing dependency, with emphasis on battery longevity.
Methods
We conducted a retrospective analysis of the first 100 LP implanted at our tertiary referral centre for cardiac devices in the UK. Demographical data as well as devices parameters at implant and latest follow ups were obtained from the patients’ medical electronic records. We compared the performance of the LPs between patients with vasovagal syncope vs other pacing indications with emphasis on battery longevity in both groups.
Results
A total of 90 patients were included in our analysis after excluding 10 patients due to lack of follow-up data. 14 patients (15.6%) had vasovagal syncope as indication for pacing and 76 patients (84.4%) had other indications. Mean ages were 34±13 years and 62±20 years for the vasovagal and the other group, respectively. There were no complications in the vasovagal group. Pacing % at the last follow up was 1±1 in the vasovagal group and 37±43 for the other group. There was a significant difference in the estimated total battery life between both groups, 15.22±0.35 and 13.65±2.97 years in the vasovagal and the other group respectively.
Conclusion
LPs provide a safe and a reliable treatment for young patients with vasovagal syncope with promising battery performance at the short/intermediate term. Further longer-term follow up data is needed to identify the true battery potential in this patient cohort.
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Affiliation(s)
- M Elrefai
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - M Abouelasaad
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - D Nettey
- University of Southampton, School of Medicine, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - P Roberts
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
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Elrefai M, Abouelasaad M, Conibear I, Wiles B, Dunn A, Coniglio S, Zemkoho A, Roberts P. The use of artificial intelligence and deep learning methods in subcutaneous implantable cardioverter defibrillator screening to optimise selection in special patient populations. Europace 2022. [DOI: 10.1093/europace/euac053.448] [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: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): Dr.Mohamed ElRefai is receiving an unrestricted grant from Boston Scientific.
Introduction
Adult congenital heart disease (ACHD) and hypertrophic cardiomyopathy (HCM) patients who require defibrillator therapy are often relatively young and may require several generator replacements in their lifetime. The increased risk of complications associated with transvenous ICDs make the subcutaneous (S-ICD) a valuable alternative. However, higher S-ICD ineligibility rates (20-40% in ACHD and 7-38% in HCM) and higher inappropriate shock rates (10.5% in ACHD and 12.5% in HCM) are observed in these populations. Unfavourable T:R ratios and dynamic changes in the R and T wave amplitudes are the primarily factors behind ineligibility and inappropriate shocks, which are most commonly caused by T wave over-sensing.
Purpose
We report a novel application of deep learning methods used to autonomously screen patients for S-ICD eligibility over a longer period than conventional screening. We hypothesise that this screening approach might achieve better patient selection and optimise S-ICD vector selection in challenging patient cohorts.
Methods
Adult patients with ACHD or HCM and a control group of normal subjects were fitted with a 24-hour ambulatory ECG with the leads placed to record their S-ICD vectors. T: R ratio throughout the recordings was analysed utilising phase space reconstruction matrices to convert the ECG signal into compressed pixel images. Whilst a convolutional neural network model was trained to provide an in-depth description of the T: R variation plot for each vector T: R variation was compared statistically using a one-way ANOVA test.
Results
20 patients (age 44.1 ±11.68, 60% male, 7 HCM, 6 ACHD and 7 control subjects) were enrolled. A significant difference was observed in the mean and median T: R values between the three groups (p<0.001). There was no difference observed in the standard deviation of T: R between the control subjects and HCM group. However, there was a statistically significant difference in the standard deviation of T: R between the control subjects and the ACHD group (p= 0.01). [see Figure].
Conclusions
T:R ratio, a main determinant for S-ICD eligibility, is significantly higher in ACHD and HCM when compared to normal hearts and it also has more tendency to fluctuate in ACHD patients when compared to HCM and normal hearts populations. We hypothesise that our novel model could be used to select S-ICD eligible patients by better characterisation of T:R ratio reducing the risk of T wave oversensing and inappropriate shocks particularly in the ACHD patients’ cohort.
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Affiliation(s)
- M Elrefai
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - M Abouelasaad
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - I Conibear
- University of Southampton, School of Medicine, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - B Wiles
- King’s College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - A Dunn
- University of Southampton, School of Maths, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - S Coniglio
- University of Southampton, School of Maths, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - A Zemkoho
- University of Southampton, School of Maths, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - P Roberts
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
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Basu S, Irving C, Roberts P, Orr Y, Casey C, Reilly C, Griffiths A, Nair P, Macdonald P, Festa M. Care Close to Home: Justification for a Second Paediatric Heart Transplant Centre in Australia. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1270] [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: 10/18/2022] Open
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8
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Elrefai M, Menexi C, Roberts P. Leadless pacemakers: where is the device? Europace 2021. [DOI: 10.1093/europace/euab116.375] [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: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Leadless pacemakers (LPs) were designed to avoid lead-related complications associated with transvenous pacing. To minimise the risk of complications, there is preference towards implanting LPs into the septal aspect of the right ventricle rather than the apex or free wall. The Transcatheter Pacing Study (TPS) and the international post-approval registry demonstrated the safety and reliability of the LP systems in real-world settings. The registry demonstrated that more than half of the LPs were implanted into the septum and most required <2 attempts at deployment. We report a radiological method of defining LP position.
Methods
We reviewed the first 100 LPs implanted at our centre. Two independent observers who didn’t implant LPs reviewed the patients’ post-implant fluoroscopy images and/or post-implant CXRs when available. The reviewers assessed the devices’ positions in postero-anterior (PA) and/or right anterior oblique (RAO) views based on conventional fluoroscopic criteria for lead position. We used the proposed criteria interchangeably on fluoroscopic images and post implant CXRs (Figure). Differences in classification of device position were resolved by consensus.
Results
Three experienced operators implanted 100 LPs at our centre. Patients (61% male) 56.6 ± 22.2 years had normal hearts (74%), ischaemic cardiomyopathies (12%), congenital heart diseases (6%), valvular pathologies (5%) and dilated cardiomyopathies (3%). Indications for pacing were symptomatic sinus node dysfunction (36%), followed by high grade atrio-ventricular block (33%), bradyarrhythmia associated with atrial tachyarrhythmias (27%) and other indications for pacing (4%). We had a 100% successful implant rate, 88% required ≤2 attempts and 70% required one attempt. There were no major complications.
We were able to classify the site of the LPs implants in a total of 90 patients who had fluoroscopic projections or chest x-rays that would allow us to classify the implant sites. A total of 32 implants were in the apex (35.6%). 28 were in mid-septum (31.1 %), 15 in the apical septum (16.7%), 14 on the septal aspect of the right ventricular inflow (15.5%) and 1 implant (1.1%) in the septum of the RV outflow tract.
Conclusion
Our proposed method of defining LP position demonstrated that the rate of implants into the true apex at our centre was highly comparable to that of the international registry. It also showed that we had lower rates of implants into the mid-septum in favour of apical septum. There were no pericardial effusions or cardiac perforations resulting from our implant procedures regardless of the site of the implant. We utilised widely used fluoroscopic and chest x-ray criteria for categorisation of the LPs implantation sites. However, a recognised limitation to our analysis is that our findings were not validated using other imaging modalities such as echocardiogram or cardiac computerised tomography (CT). Abstract Figure. Criteria to classify device position
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Affiliation(s)
- M Elrefai
- Southampton General Hospital, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - C Menexi
- Southampton General Hospital, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - P Roberts
- Southampton General Hospital, Southampton, United Kingdom of Great Britain & Northern Ireland
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9
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Menexi C, Elrefai M, Abouelasaad M, Roberts P. Leadless pacemakers: does location matter? Europace 2021. [DOI: 10.1093/europace/euab116.376] [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: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Leadless pacemakers (LPs) provide a viable alternative for patients who have an indication for pacing where transvenous pacing is not desirable or possible. Registries have demonstrated stable performance associated with LPs. There is preference towards implanting LPs into the trabeculated septum rather than the apex or free wall. We report our experience with the impact of the implantation site on acute and long-term electrical performance of LPs.
Methods
We ran a retrospective analysis on the first 100 LPS implanted at our centre. Two independent observers reviewed the fluoroscopic images and post-implant chest x-rays to classify the LPs’ positions. We obtained the recorded pacing threshold , R-wave amplitude and impedance of the devices at the time of implant and at the latest available routine device follow-up. We used one-way ANOVA testing to compare the acute and long-term electrical performance of the LPs between different implantation sites.
Results
We were able to classify the site of the LPs implants in a total of 90 patient. 84 Patients (60% male) 57.3± 22.16 years were included .23.8% of the patients presented with syncope. Indications for pacing were symptomatic sinus node dysfunction (33.3%), high grade AV block (34.5%), bradyarrhythmia associated with atrial tachyarrhythmias (28.6%) and other indications (3.6%). We had a 100% successful implant rate, 85.7% required ≤2 attempts and 71.4% required one attempt. A total of 32 implants were in the apex (38.1%), 26 in mid-septum (30.9 %), 13 in the apical septum (15.5%), 12 on the septal aspect of the right ventricular inflow (14.3%) and 1 implant (1.2%) in the septum of the RV outflow tract.
The follow up period of the 84 patients was 3.09 ± 1.97 years. 100% of the LPs had the pacing thresholds <2.0 V @0.24 ms at the time of implant. Pacing threshold, R-wave amplitude, and impedance averaged at 0.67 ± 0.41 V, 10.86 ± 5.41 mV, and 775 ± 193.28 Ohms respectively at the time of implantation and 0.66 ± 0.39 V, 14.08 ± 6.14 mV, and 564.29 ± 96.76 Ohms at the last device check. There was no statistically significant difference in either the pacing thresholds or the impedance between implant sites. Post hocTukey’s analysis (excluding the outflow tract case) demonstrated significant statistical difference in the R-wave amplitudes between implants at the apex and the mid-septum both at the time of implantation (12.9 ± 6.1 mV and 8.53 ± 2.84 mV; p = 0.0196) and at follow up (15.97 ± 5.35 mV and 11.52 ± 5.01 mV; p = 0.0415). There were no differences between other sites
Conclusions
Our analysis demonstrated that aside from the difference between the sensed R wave amplitudes between LPs implanted at the apex and those implanted at mid-septum , there was no statistically significant difference in the acute or the long term electrical performance of implanted LPs regardless of the implantation site. A limitation to our analysis is the relatively low number of LP implants included in our analysis. Abstract Figure. Mean of parameters by validated position
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Affiliation(s)
- C Menexi
- Southampton General Hospital, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - M Elrefai
- Southampton General Hospital, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - M Abouelasaad
- Southampton General Hospital, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - P Roberts
- Southampton General Hospital, Southampton, United Kingdom of Great Britain & Northern Ireland
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10
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Tetlow S, Segiet-Swiecicka A, O'Sullivan R, O'Halloran S, Kalb K, Brathwaite-Shirley C, Alger L, Ankuli A, Baig MS, Catmur F, Chan T, Dudley D, Fisher J, Iqbal MU, Puczynska J, Wilkins R, Bygate R, Roberts P. ACE inhibitors, angiotensin receptor blockers and endothelial injury in COVID-19. J Intern Med 2021; 289:688-699. [PMID: 33210357 PMCID: PMC7753609 DOI: 10.1111/joim.13202] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/15/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND COVID-19 is caused by the coronavirus SARS-CoV-2, which uses angiotensin-converting enzyme 2 (ACE-2) as a receptor for cellular entry. It is theorized that ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) may increase vulnerability to SARS-CoV-2 by upregulating ACE-2 expression, but ACE-I/ARB discontinuation is associated with clinical deterioration. OBJECTIVE To determine whether ACE-I and ARB use is associated with acute kidney injury (AKI), macrovascular thrombosis and in-hospital mortality. METHODS A retrospective, single-centre study of 558 hospital inpatients with confirmed COVID-19 admitted from 1 March to 30 April 2020, followed up until 24 May 2020. AKI and macrovascular thrombosis were primary end-points, and in-hospital mortality was a secondary end-point. RESULTS AKI occurred in 126 (23.1%) patients, 34 (6.1%) developed macrovascular thrombi, and 200 (35.9%) died. Overlap propensity score-weighted analysis showed no significant effect of ACE-I/ARB use on the risk of occurrence of the specified end-points. On exploratory analysis, severe chronic kidney disease (CKD) increases odds of macrovascular thrombi (OR: 8.237, 95% CI: 1.689-40.181, P = 0.009). The risk of AKI increased with advancing age (OR: 1.028, 95% CI: 1.011-1.044, P = 0.001) and diabetes (OR: 1.675, 95% CI: 1.065-2.633, P = 0.025). Immunosuppression was associated with lower risk of AKI (OR: 0.160, 95% CI: 0.029-0.886, P = 0.036). Advancing age, dependence on care, male gender and eGFR < 60 mL min-1 /1.73 m2 increased odds of in-hospital mortality. CONCLUSION We did not identify an association between ACE-I/ARB use and AKI, macrovascular thrombi or mortality. This supports the recommendations of the European and American Societies of Cardiology that ACE-Is and ARBs should not be discontinued during the COVID-19 pandemic.
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Affiliation(s)
- S Tetlow
- From the, Department of Acute Medicine, University College Hospital, Bloomsbury, London, UK
| | - A Segiet-Swiecicka
- Chair and Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warszawa, Poland.,Department of Coronary Artery Disease and Cardiac Rehabilitation, Cardinal Stefan Wyszynski Institute of Cardiology, Warszawa, Poland
| | - R O'Sullivan
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - S O'Halloran
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - K Kalb
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | | | - L Alger
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - A Ankuli
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - M S Baig
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - F Catmur
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - T Chan
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - D Dudley
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - J Fisher
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - M U Iqbal
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - J Puczynska
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - R Wilkins
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
| | - R Bygate
- Department of Acute Medicine, Newham University Hospital NHS Trust, Newham University Hospital, London, UK
| | - P Roberts
- Department of Critical Care, Lewisham and Greenwich NHS Trust, London, UK
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11
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Halstead FD, Quick J, Niebel M, Garvey M, Cumley N, Smith R, Neal T, Roberts P, Hardy K, Shabir S, Walker JT, Hawkey P, Loman NJ. Pseudomonas aeruginosa infection in augmented care: the molecular ecology and transmission dynamics in four large UK hospitals. J Hosp Infect 2021; 111:162-168. [PMID: 33539934 DOI: 10.1016/j.jhin.2021.01.020] [Citation(s) in RCA: 3] [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: 12/21/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pseudomonas aeruginosa is a common opportunistic pathogen and molecular typing in outbreaks has linked patient acquisition to contaminated hospital water systems. AIM To elucidate the role of P. aeruginosa transmission rates in non-outbreak augmented care settings in the UK. METHODS Over a 16-week period, all water outlets in augmented care units of four hospitals were sampled for P. aeruginosa and clinical isolates were collected. Outlet and clinical P. aeruginosa isolates underwent whole-genome sequencing (WGS), which with epidemiological data identified acquisition from water as definite (level 1), probable (level 2), possible (level 3), and no evidence (level 4). FINDINGS Outlets were positive in each hospital on all three occasions: W (16%), X (2.5%), Y (0.9%) and Z (2%); and there were 51 persistently positive outlets in total. WGS identified likely transmission (at levels 1, 2 and 3) from outlets to patients in three hospitals for P. aeruginosa positive patients: W (63%), X (54.5%) and Z (26%). According to the criteria (intimate epidemiological link and no phylogenetic distance), approximately 5% of patients in the study 'definitely' acquired their P. aeruginosa from their water outlets in the intensive care unit. This study found extensive evidence of transmission from the outlet to the patients particularly in the newest hospital (W), which had the highest rate of positive outlets. CONCLUSIONS The overall findings suggest that water outlets are the most likely source of P. aeruginosa nosocomial infections in some settings, and that widespread introduction of control measures would have a substantial impact on infections.
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Affiliation(s)
- F D Halstead
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK; Department of Clinical Microbiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Quick
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK; Institute of Microbiology and Infection, School of Biosciences, University of Birmingham, Birmingham, UK
| | - M Niebel
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK; Department of Clinical Microbiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M Garvey
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK; Department of Clinical Microbiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - N Cumley
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK; Department of Clinical Microbiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Smith
- Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - T Neal
- Royal Liverpool University Hospital, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - P Roberts
- Royal Liverpool University Hospital, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - K Hardy
- Public Health England, Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - S Shabir
- Public Health England, Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | | | - P Hawkey
- Department of Clinical Microbiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Microbiology and Infection, School of Biosciences, University of Birmingham, Birmingham, UK.
| | - N J Loman
- Institute of Microbiology and Infection, School of Biosciences, University of Birmingham, Birmingham, UK
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12
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Luxford J, Adams P, Roberts P, Mervis J. Right Ventricular Outflow Tract Stenting in Infants Less Than 3.5kg to Augment Pulmonary Blood Flow Prior to Surgical Repair of Tetralogy of Fallot. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.388] [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: 10/20/2022]
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13
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Cao B, Mervis J, Adams P, Roberts P, Ayer J. Branch Pulmonary Artery Stent Angioplasty in Children Less Than 10kg. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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14
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Cai Y, Haghighi M, Roberts P, Mervis J, Qasem A, Butlin M, Celermajer D, Avolio A, Skilton M, Ayer J. 061 Validity of Carotid Artery Tonometry for Estimating Central Hemodynamic Indices in Children. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.068] [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: 11/28/2022]
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15
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Tarakji K, Zweibel S, Seiler A, Roberts P, Shaik N, Silverstein J, Patwala A, Mittal S, Molon G, Augello G, Porfilio A, Holloman K, Varma N, Sears S, Turakhia M. P577Early experience with the first pacemakers to directly connect with smart devices for remote monitoring. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Remote monitoring is associated with improved patient outcomes; however, adoption and adherence to remote monitoring via home-based consoles remains suboptimal. BlueSync technology in new generation pacemaker and CRT-P models enables the implanted device to communicate directly with patient-owned, Bluetooth-equipped smartphones/tablets and an app (MyCareLink Heart). The app can automatically retrieve information from the cardiac device and transmit the data to the remote network, eliminating the need for traditional remote monitoring consoles.
Objectives
To characterize the communication process between implanted pacemakers and smart device remote monitoring apps by assessing the success of prescheduled remote transmissions in the first month of follow-up. Additionally, to assess the feedback of both patients and clinicians about the process of device pairing.
Methods
Enrollment in the BlueSync Field Evaluation began in April 2018 and was completed November 2018. Follow-up is ongoing. Prior to enrollment in the evaluation, patients completed the device pairing process with the app using their own compatible smartphone or tablet. Patient and clinician questionnaires were completed at the time of the device pairing process. After enrollment, successful completion of scheduled transmissions occurring in the first month were analyzed.
Results
Preliminary data includes 241 enrolled patients with mean age of 64.7±15.5 yrs (min 20, max 90 yrs), who completed device pairing between their implanted device and their smart device app. Of enrolled patients, 79% felt that the device paring was easy to do, 85% were satisfied with the amount of time it took to complete it, and 93% felt that they would be comfortable using the app. Clinicians reported that 67% of the device pairings took less than 20 minutes and 78% felt patients would be able to use the app independently. At the time of analysis 174 patients had at least one scheduled transmission within the first month, and collectively had a total of 322 scheduled transmissions. Out of these, 309 (96%, 95% CI: 93%-98%) were successfully completed.
MyCareLink Heart App
Conclusions
Initial experience with the world's first app based remote monitoring system for Bluetooth enabled pacemakers demonstrated success to scheduled transmissions in the first month across a wide range of patient ages. Patients and clinicians reported high satisfaction with this novel technology.
Acknowledgement/Funding
Medtronic PLC
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Affiliation(s)
- K Tarakji
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - S Zweibel
- Hartford Hospital, Hartford, United States of America
| | - A Seiler
- Moses Cone Heart and Vascular Center, Greensboro, United States of America
| | - P Roberts
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - N Shaik
- Cardiovascular Institutes, Orlando, United States of America
| | | | - A Patwala
- North Staffordshire NHS Trust, Cardiology, Stoke on Trent, United Kingdom
| | - S Mittal
- The Valley Hospital, Ridgewood, United States of America
| | - G Molon
- Sacred Heart Hospital of Negrar, Negrar, Italy
| | - G Augello
- Istituto Clinico Citta Studi, Cardiology, Milano, Italy
| | - A Porfilio
- Provincia Religiosa San Pietro Di Roma, Roma, Italy
| | - K Holloman
- Medtronic PLC, Clinical Research, Mounds View, United States of America
| | - N Varma
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - S Sears
- East Carolina University, Greenville, United States of America
| | - M Turakhia
- Stanford University, Palo Alto, United States of America
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16
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Bradshaw D, Rae C, Rayment M, Turner N, Turner R, Pickard G, Pillay K, Roberts P, Foxton M, Sullivan AK. HIV/HCV/HBV testing in the emergency department: a feasibility and seroprevalence study. HIV Med 2019; 19 Suppl 1:52-57. [PMID: 29488696 DOI: 10.1111/hiv.12590] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aims of this study were to to assess the feasibility of simultaneous testing for the blood-borne viruses (BBV), HIV, hepatitis C (HCV) and hepatitis B (HBV), in the Emergency Department (ED) and ascertain the seroprevalence for these three viruses in this setting. METHODS A pilot BBV testing program was undertaken as part of routine clinical care in the ED. All ED attendees aged between 16 and 65 years old who were able to consent were tested over a 55 week period on an opt out basis. Patients with positive test results were linked to clinical services. Interventions aimed at improving testing rates were implemented and evaluated by quality improvement (QI) methodology. RESULTS Of 25,520 age-eligible ED attendees, 6108 (24%) underwent BBV testing; an additional 1160 (4.5%) underwent a standalone HIV test (total of 7268 (28%) individuals).There were 83/7268 (1.1%) non-negative (ie reactive or equivocal) results for HIV and 103/6108 (1.7%) and 32/6108 (0.52%) for anti-HCV IgG and HBsAg, respectively. Of these, 12 (0.17%), 16 (0.26%) and 8 (0.13%) were new reactive tests for HIV, HCV and HBV, respectively, which were able to be confirmed on a second test. Specific QI interventions led to temporary increases in testing rates. CONCLUSIONS An opt out BBV testing program in the ED is feasible and effective at finding new cases. However, the testing rate was low at 24%. Although QI interventions led to some improvement in testing rates, further studies are required to identify ways to achieve sustained increases in testing in this setting.
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Affiliation(s)
- D Bradshaw
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - C Rae
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - M Rayment
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - N Turner
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - R Turner
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - G Pickard
- Imperial College Healthcare NHS Trust, London, UK
| | - K Pillay
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - P Roberts
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - M Foxton
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - A K Sullivan
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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17
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Leake PA, Toppin P, Reid M, Plummer J, Roberts P, Harding-Goldson H, McFarlane M. Improving patient outcomes with inguinal hernioplasty-local anaesthesia versus local anaesthesia and conscious sedation: a randomized controlled trial. Hernia 2019; 23:561-567. [PMID: 30847720 DOI: 10.1007/s10029-019-01922-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/25/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Conscious sedation is regularly used in ambulatory surgery to improve patient outcomes, in particular patient satisfaction. We hypothesized that the addition of conscious sedation would provide greater patient satisfaction with inguinal hernioplasty compared to local anesthesia alone. METHODS This trial was a single-centre, randomized, placebo-controlled, double-blinded trial where patients undergoing inguinal hernioplasty using local anaesthesia were randomized to receive local anaesthesia alone versus local anaesthesia and conscious sedation. The primary outcome of patient satisfaction was assessed using the Iowa Satisfaction with Anesthesia Scale (ISAS). The study was powered to detect a significant difference in ISAS scores between groups. Comparisons were made using T test and Chi square tests. A p value of less than 0.05 was considered significant. RESULTS There were 149 patients randomized: 78 to the local anesthesia (LA) group and 71 to the local anaesthesia and conscious sedation (LACS) group. For the primary outcome measure of patient satisfaction, the mean ISAS score was significantly greater in the LACS group (p = 0.009). The experience of pain and pain severity was greater in the LA group (p = 0.016; p = 0.0162 respectively). No statistically significant difference was found between groups with respect to operative time, time to discharge or postoperative complications. CONCLUSION The use of conscious sedation with local anesthesia for inguinal hernioplasty is safe, results in less pain experience and severity and is associated with better patient satisfaction. The use of conscious sedation does not delay patient discharge.
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Affiliation(s)
- P-A Leake
- Division of General Surgery, Department of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston 7, Jamaica.
| | - P Toppin
- Division of Anaesthesia, Department of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston 7, Jamaica
| | - M Reid
- Tropical Metabolic Research Institute, University of the West Indies, Mona, Kingston 7, Jamaica
| | - J Plummer
- Division of General Surgery, Department of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston 7, Jamaica
| | - P Roberts
- Division of General Surgery, Department of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston 7, Jamaica
| | - H Harding-Goldson
- Division of Anaesthesia, Department of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston 7, Jamaica
| | - M McFarlane
- Division of General Surgery, Department of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston 7, Jamaica
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18
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Hausmann N, Prendergast AL, Lemonis A, Zech J, Roberts P, Siozos P, Anglos D. Extensive elemental mapping unlocks Mg/Ca ratios as climate proxy in seasonal records of Mediterranean limpets. Sci Rep 2019; 9:3698. [PMID: 30842602 PMCID: PMC6403426 DOI: 10.1038/s41598-019-39959-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 01/23/2019] [Indexed: 11/09/2022] Open
Abstract
Elemental analysis of biogeochemical archives is an established technique used to study climate in a range of applications, including ocean circulation, glacial/interglacial climates, and anthropogenic climate change. Data from mollusc archives are especially important because of their global abundance and sub-annual resolution. Despite this potential, they are underrepresented among palaeoclimate studies, due to enigmatic physiological influences skewing the elemental record. Understanding the patterns behind these influences will improve data interpretation and lead to the development of new climate proxies. Here, we show for the first time that extensive spatial mapping of multiple mollusc specimens using Laser Induced Breakdown Spectroscopy (LIBS) across a wider region can resolve enigmatic patterns within the elemental record caused by physiological influences. 2D elemental (Mg/Ca) maps of whole limpet shells (Patella caerulea) from across the Mediterranean revealed patterns of variability within individual mollusc records as well as within isochronous parts of specimens. By registering and quantifying these patterns, we established previously uninterpretable correlations with temperature (R2 > 0.8, p < 0.01). This outcome redefines the possibilities of accessing sub-annual climate proxies and presents the means to assess annual temperature ranges using oxygen isotope analysis requiring only 2 samples per shell.
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Affiliation(s)
- N Hausmann
- Institute of Electronic Structure and Laser, Foundation for Research and Technology - Hellas, Heraklion, Greece. .,BioArCh, Department of Archaeology, University of York, York, United Kingdom. .,Department of Archaeology, Max Planck Institute for the Science of Human History, Jena, Germany.
| | - A L Prendergast
- School of Geography, University of Melbourne, Melbourne, Australia
| | - A Lemonis
- Department of Chemistry, University of Crete, Heraklion, Greece
| | - J Zech
- Department of Archaeology, Max Planck Institute for the Science of Human History, Jena, Germany
| | - P Roberts
- Department of Archaeology, Max Planck Institute for the Science of Human History, Jena, Germany
| | - P Siozos
- Institute of Electronic Structure and Laser, Foundation for Research and Technology - Hellas, Heraklion, Greece
| | - D Anglos
- Institute of Electronic Structure and Laser, Foundation for Research and Technology - Hellas, Heraklion, Greece.,Department of Chemistry, University of Crete, Heraklion, Greece
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19
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Lawley C, Tanous D, Anderson B, Celermajer D, Wilson W, Shipton S, O’Donnell C, Roberts P. Percutaneous Pulmonary Valve Implantation (PPVI) in Australia and New Zealand (ANZ). Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.507] [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: 11/30/2022]
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20
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Knetsch CW, Kumar N, Forster SC, Connor TR, Browne HP, Harmanus C, Sanders IM, Harris SR, Turner L, Morris T, Perry M, Miyajima F, Roberts P, Pirmohamed M, Songer JG, Weese JS, Indra A, Corver J, Rupnik M, Wren BW, Riley TV, Kuijper EJ, Lawley TD. Zoonotic Transfer of Clostridium difficile Harboring Antimicrobial Resistance between Farm Animals and Humans. J Clin Microbiol 2018; 56:e01384-17. [PMID: 29237792 PMCID: PMC5824051 DOI: 10.1128/jcm.01384-17] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [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: 08/29/2017] [Accepted: 12/08/2017] [Indexed: 11/20/2022] Open
Abstract
The emergence of Clostridium difficile as a significant human diarrheal pathogen is associated with the production of highly transmissible spores and the acquisition of antimicrobial resistance genes (ARGs) and virulence factors. Unlike the hospital-associated C. difficile RT027 lineage, the community-associated C. difficile RT078 lineage is isolated from both humans and farm animals; however, the geographical population structure and transmission networks remain unknown. Here, we applied whole-genome phylogenetic analysis of 248 C. difficile RT078 strains from 22 countries. Our results demonstrate limited geographical clustering for C. difficile RT078 and extensive coclustering of human and animal strains, thereby revealing a highly linked intercontinental transmission network between humans and animals. Comparative whole-genome analysis reveals indistinguishable accessory genomes between human and animal strains and a variety of antimicrobial resistance genes in the pangenome of C. difficile RT078. Thus, bidirectional spread of C. difficile RT078 between farm animals and humans may represent an unappreciated route disseminating antimicrobial resistance genes between humans and animals. These results highlight the importance of the "One Health" concept to monitor infectious disease emergence and the dissemination of antimicrobial resistance genes.
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Affiliation(s)
- C W Knetsch
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - N Kumar
- Host-Microbiota Interactions Laboratory, Wellcome Trust Sanger Institute, Hinxton, United Kingdom
| | - S C Forster
- Host-Microbiota Interactions Laboratory, Wellcome Trust Sanger Institute, Hinxton, United Kingdom
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria, Australia
| | - T R Connor
- Cardiff School of Biosciences, Sir Martin Evans Building, Cardiff, United Kingdom
| | - H P Browne
- Host-Microbiota Interactions Laboratory, Wellcome Trust Sanger Institute, Hinxton, United Kingdom
| | - C Harmanus
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - I M Sanders
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - S R Harris
- Pathogen Genomics, Wellcome Trust Sanger Institute, Hinxton, United Kingdom
| | - L Turner
- Public Health Wales, Microbiology, Wales, United Kingdom
| | - T Morris
- Public Health Wales, Microbiology, Wales, United Kingdom
| | - M Perry
- Public Health Wales, Microbiology, Wales, United Kingdom
| | - F Miyajima
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - P Roberts
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - M Pirmohamed
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - J G Songer
- Department of Veterinary Science and Microbiology, The University of Arizona, Tucson, Arizona, USA
| | - J S Weese
- Department of Pathobiology, Canada Veterinary College, University of Guelph, Guelph, Canada
| | - A Indra
- Institute of Medical Microbiology and Hygiene, Österreichische Agentur für Gesundheit und Ernährungssicherheit (AGES), Vienna, Austria
| | - J Corver
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - M Rupnik
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
- National Laboratory for Health, Environment and Food, Maribor, Slovenia
| | - B W Wren
- Department of Pathogen Molecular Biology, London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | - T V Riley
- Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Western Australia, Australia
- Microbiology & Immunology, School of Pathology & Laboratory Medicine, The University of Western Australia, Western Australia, Australia
| | - E J Kuijper
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - T D Lawley
- Host-Microbiota Interactions Laboratory, Wellcome Trust Sanger Institute, Hinxton, United Kingdom
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21
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Poller B, Hall S, Bailey C, Gregory S, Clark R, Roberts P, Tunbridge A, Poran V, Crook B, Evans C. 'VIOLET': a fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment. J Hosp Infect 2018; 99:229-235. [PMID: 29421340 PMCID: PMC7133760 DOI: 10.1016/j.jhin.2018.01.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/30/2018] [Indexed: 01/06/2023]
Abstract
Background Healthcare workers caring for patients with high-consequence infectious diseases (HCIDs) require protection from pathogen exposure, for example by wearing personal protective equipment (PPE). Protection is acquired through the inherent safety of the PPE components, but also their safe and correct use, supported by adequate training and user familiarity. However, the evidence base for HCID PPE ensembles and any associated training is lacking, with subsequent variation between healthcare providers. Aim To develop an evidence-based assessment and training tool for evaluating PPE ensembles and doffing protocols, in the assessment of patients with suspected HCIDs. Methods VIOLET (Visualising Infection with Optimised Light for Education and Training) comprises a healthcare mannequin adapted to deliver simulated bodily fluids containing UV-fluorescent tracers. On demand and remotely operated, the mannequin projectile vomits (blue), coughs (red), has diarrhoea (yellow) and is covered in sweat (orange). Wearing PPE, healthcare staff participate in an HCID risk assessment and examination of the ‘patient’, thereby becoming exposed to these bodily fluids. Contamination of PPE is visualized and body-mapped under UV light before and after removal. Observational findings and participant feedback, around its use as a training exercise, is also recorded. Findings Significant contamination from different exposure events was seen, enabling evaluation of PPE and doffing procedures used. Observational data and participant feedback demonstrated its strengths and success as a training technique. Conclusion Simulation exercises using VIOLET provide evidence-based assessment of PPE ensembles, and are a valuable resource for training of healthcare staff in wearing and safe doffing of PPE.
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Affiliation(s)
- B Poller
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
| | - S Hall
- Health and Safety Executive, Buxton, UK
| | - C Bailey
- Health and Safety Executive, Buxton, UK
| | - S Gregory
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - R Clark
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - P Roberts
- Health and Safety Executive, Buxton, UK
| | - A Tunbridge
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - V Poran
- Health and Safety Executive, Leeds, UK
| | - B Crook
- Health and Safety Executive, Buxton, UK
| | - C Evans
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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22
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Hein L, White L, Miles A, Roberts P. Analysing the impacts of air quality policies on ecosystem services; a case study for Telemark, Norway. J Environ Manage 2018; 206:650-663. [PMID: 29132088 DOI: 10.1016/j.jenvman.2017.10.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 09/01/2017] [Accepted: 10/30/2017] [Indexed: 06/07/2023]
Abstract
There is an increasing interest in considering the effects of air pollution on ecosystem services supply in order to enhance cost-benefit analyses of air pollution policies. This paper presents a generic, conceptual approach that can be used to link atmospheric deposition of air pollutants to ecosystem services supply and societal benefits. The approach is applied in a case study in the Telemark county of Norway. First, we examine the potential effects of four European air quality policy scenarios on N deposition in the ecosystems of this county. Second, we analyse the subsequent impacts on the supply of three ecosystem services: carbon sequestration, timber production and biodiversity. Changes in the supply of the first two services are analysed in both physical and monetary units, biodiversity effects are only analysed in physical terms. The scenarios derive from work conducted in the context of the European National Emissions Ceilings Directive. In the 2010 base case the benefits of carbon sequestration are estimated at 13 million euro per year and the value of timber harvesting at 2.9 million euro per year. Under the examined policy scenarios aiming to reduce nitrogen emissions the societal benefits resulting from these two ecosystem services in Telemark are found to be reduced; the scenarios have little effect on terrestrial biodiversity. Such results cannot be scaled up, individual ecosystem services respond differently to changes in air pollution depending upon type of pollutant, type of ecosystem, type of service, and the magnitude of change. The paper further presents an analysis of the uncertainties that need to be considered in linking air pollution and ecosystem services including those in deposition rates, ecosystem responses, human responses and in the values of ecosystem services. Our conceptual approach is also useful for larger scale analysis of air pollution effects on ecosystem services, for example at national or potentially European scale.
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Affiliation(s)
- L Hein
- Environmental Systems Analysis Group, Wageningen University, P.O. Box 47, 6700 AA, Wageningen, The Netherlands.
| | - L White
- Aeris Europe, Strouds, Church Lane, Horsted Keynes, RH17 7AY, UK
| | - A Miles
- Aeris Europe, Strouds, Church Lane, Horsted Keynes, RH17 7AY, UK
| | - P Roberts
- Concawe, Boulevard du Souverain 165, B-1160, Brussels, Belgium
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23
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Hall S, Poller B, Bailey C, Gregory S, Clark R, Roberts P, Tunbridge A, Poran V, Evans C, Crook B. Use of ultraviolet-fluorescence-based simulation in evaluation of personal protective equipment worn for first assessment and care of a patient with suspected high-consequence infectious disease. J Hosp Infect 2018; 99:218-228. [PMID: 29325871 DOI: 10.1016/j.jhin.2018.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 11/20/2017] [Accepted: 01/03/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Variations currently exist across the UK in the choice of personal protective equipment (PPE) used by healthcare workers when caring for patients with suspected high-consequence infectious diseases (HCIDs). AIM To test the protection afforded to healthcare workers by current PPE ensembles during assessment of a suspected HCID case, and to provide an evidence base to justify proposal of a unified PPE ensemble for healthcare workers across the UK. METHODS One 'basic level' (enhanced precautions) PPE ensemble and five 'suspected case' PPE ensembles were evaluated in volunteer trials using 'Violet'; an ultraviolet-fluorescence-based simulation exercise to visualize exposure/contamination events. Contamination was photographed and mapped. FINDINGS There were 147 post-simulation and 31 post-doffing contamination events, from a maximum of 980, when evaluating the basic level of PPE. Therefore, this PPE ensemble did not afford adequate protection, primarily due to direct contamination of exposed areas of the skin. For the five suspected case ensembles, 1584 post-simulation contamination events were recorded, from a maximum of 5110. Twelve post-doffing contamination events were also observed (face, two events; neck, one event; forearm, one event; lower legs, eight events). CONCLUSION All suspected case PPE ensembles either had post-doffing contamination events or other significant disadvantages to their use. This identified the need to design a unified PPE ensemble and doffing procedure, incorporating the most protective PPE considered for each body area. This work has been presented to, and reviewed by, key stakeholders to decide on a proposed unified ensemble, subject to further evaluation.
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Affiliation(s)
- S Hall
- Health and Safety Executive, Buxton, UK.
| | - B Poller
- Sheffield Teaching Hospitals NHS Trusts, Sheffield, UK
| | - C Bailey
- Health and Safety Executive, Buxton, UK
| | - S Gregory
- Sheffield Teaching Hospitals NHS Trusts, Sheffield, UK
| | - R Clark
- Sheffield Teaching Hospitals NHS Trusts, Sheffield, UK
| | - P Roberts
- Health and Safety Executive, Buxton, UK
| | - A Tunbridge
- Sheffield Teaching Hospitals NHS Trusts, Sheffield, UK
| | - V Poran
- Health and Safety Executive, Leeds, UK
| | - C Evans
- Sheffield Teaching Hospitals NHS Trusts, Sheffield, UK
| | - B Crook
- Health and Safety Executive, Buxton, UK
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24
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Nguyen S, Fogarty S, Nicolae M, Roberts P. Valve-in-Valve-in-Valve: Percutaneous Tricuspid Valve Rehabilitation for a Stenosed Percutaneous Implanted 26-mm Edwards SAPIEN Valve in a Young Man With Complex Congenital Heart Disease. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.819] [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: 11/15/2022]
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25
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26
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El-Chami M, Kowal R, Johansen JB, Zaidi O, Mont L, Iacopino S, Faerestrand S, Li S, Van Osch D, Roberts P. P435Is it safe to implant a leadless pacemaker in patients with existing CIEDs? Experience from the Micra post market registry. Europace 2017. [DOI: 10.1093/ehjci/eux141.158] [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: 11/13/2022] Open
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27
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Roberts P, He S, Schvartsman G, Patil T, Sorrentio J, Bisi J, Hoyer R, Schuster S, Strum J, Heymach J, Ferrarotto R, Sharpless N, Shapiro G, Malik R. G1T28, a CDK4/6 inhibitor, preserves T lymphocyte function from damage by cytotoxic chemotherapy. Eur J Cancer 2016. [DOI: 10.1016/s0959-8049(16)33026-x] [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: 11/26/2022]
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28
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Waterman CA, Batstone P, Bown N, Cresswell L, Delmege C, English CJ, Fews G, Grimsley L, Imrie S, Kulkarni A, Mann K, Johnson R, Morgan SM, Roberts P, Simonic I, Trueman S, Wall M, McMullan D. The clinical utility of genetic testing of tissues from pregnancy losses. BJOG 2016; 125:867-873. [PMID: 27594580 DOI: 10.1111/1471-0528.14229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To map the current testing being undertaken following pregnancy loss across the UK and to examine the clinical utility in terms of identifying a cause for the loss and in identifying couples at risk of an unbalanced liveborn child. DESIGN Retrospective audit. SETTING UK, for the year 2014. POPULATION An audit of 6465 referrals for genetic testing of tissue samples following pregnancy loss. METHODS Data were obtained by questionnaire from 15 UK regional genetics laboratories. MAIN OUTCOME MEASURES Data were analysed with respect to gestational age, the presence of identified fetal anomalies, methodologies used, abnormality rates and the presence of a parental balanced rearrangement. RESULTS Of 6465 referrals a genetic cause was identified in 22% of cases (before 12 weeks' gestation, in 47%; at 12-24 weeks, in 14%; after 24 weeks, in 6%). In 0.4% of cases a balanced parental rearrangement was identified where there was a risk of an affected liveborn child in a future pregnancy. Eighty percent of genetic imbalances identified were aneuploidy or triploidy and could be identified by quantitative fluorescence polymerase chain reaction alone. There was significant variation across the UK in acceptance criteria, testing strategies and thus level of resolution of testing. CONCLUSIONS Genetic testing of tissues following pregnancy loss identifies a probable cause of fetal demise in 22% of cases, but it is of low clinical utility in identifying couples at risk of a future unbalanced liveborn child. A comprehensive multidisciplinary review is needed to develop proposals for an affordable and equitable service. TWEETABLE ABSTRACT UK audit of genetic testing of fetal loss shows variation in access to and resolution of analysis.
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Affiliation(s)
- C A Waterman
- Wessex Regional Genetics Laboratory, Salisbury, UK
| | - P Batstone
- Aberdeen Medical Genetics Laboratory, Aberdeen, UK
| | - N Bown
- Northern Genetics Service, Newcastle upon Tyne, UK
| | - L Cresswell
- Cytogenetics Department, University Hospitals of Leicester, Leicester, UK
| | - C Delmege
- Bristol Genetics Laboratory, Bristol, UK
| | - C J English
- Northern Genetics Service, Newcastle upon Tyne, UK
| | - G Fews
- West Midlands Regional Genetics Laboratory, Birmingham, UK
| | - L Grimsley
- NE Thames Regional Genetics Laboratory, London, UK
| | - S Imrie
- West of Scotland Genetics Services, Glasgow, UK
| | - A Kulkarni
- Genetics Department, St George's Healthcare NHS Trust, London, UK
| | - K Mann
- Genetics Department, Viapath Analytics, Guy's Hospital, London, UK
| | - R Johnson
- Genetics Department, St George's Healthcare NHS Trust, London, UK
| | - S M Morgan
- All Wales Medical Genetics Service, Cardiff, UK
| | - P Roberts
- Yorkshire Regional Genetics Service, Leeds, UK
| | - I Simonic
- East Anglian Medical Genetics Service, Cambridge, UK
| | - S Trueman
- Manchester Centre for Genomic Medicine, Manchester, UK
| | - M Wall
- Cytogenetics department, Royal Marsden Hospital, London, UK
| | - D McMullan
- West Midlands Regional Genetics Laboratory, Birmingham, UK
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29
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Ryan JM, Roberts P. Definitive surgical trauma skills: a new skills course for specialist registrars and consultants in general surgery in the United Kingdom. Trauma 2016. [DOI: 10.1191/1460408602ta240oa] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In an era of increasing subspecialization within UK surgical practice, few senior trainees and a diminishing number of consultants feel competent operating outside their chosen specialist eld. General surgery and orthopaedic trainees, however, remain in the front line of trauma management. Subspecialization is, to some degree, affecting training of orthopaedic surgeons; there are some that do not deal with trauma. However, it is in the so-called field of general surgery that subspecialization has had the greatest impact. Many trainees are now more familiar with endoscopic techniques than open laparotomy and, even within the open abdomen, few wish to explore organ systems or regions outside their `zone of comfort’. Trauma, especially that inflicted by rearms, does not respect anatomical or speciality boundaries. This raises the question of how best to train surgeons in the future to manage severe multisystem injury. To manage trauma competently there is a need to master operative skills that cover the whole of the abdominal cavity, including the pelvis and the retroperitoneum. General surgeons should be competent and confident to carry out trauma thoracotomies and able to cope with central and peripheral vascular trauma. Further skills and knowledge are also required: these encompass trauma epidemiology, critical decision making and, not least, a detailed knowledge of surgical anatomy. Knowledge can be most severely tested when dealing with multi-system trauma! There is also a particular need to give military surgeons the competencies required to deal with battlefield trauma, 90% of which is caused by penetrating injury. Military surgeons, by definition, still need to be `generalists’. The Raven department of education at the Royal College of Surgeons of England, the Royal Defence Medical College (now the Royal Centre for Defence Medicine, Birmingham), and the Uniformed Services University of the Health Sciences, Washington, have developed a Definitive Surgical Trauma Skills (DSTS) course to meet this specific training need. This tripartite venture was developed in association with the Societe International de Chirugie (SIC) and the International Association for the Surgery of Trauma and Surgical Intensive Care (IATSIC).
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Affiliation(s)
- JM Ryan
- Raven Department of Education, Royal College of Surgeons of England, London, UK,
| | - P Roberts
- Raven Department of Education, Royal College of Surgeons of England, London, UK
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30
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Losk K, Mallory M, Caterson S, Camuso K, Cutone L, Roberts P, Lin N, Bunnell C, Golshan M. Abstract P2-13-12: Implementation of a breast/reconstructive surgery coordinator to reduce preoperative delays for patients undergoing mastectomy with immediate reconstruction. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p2-13-12] [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
Abstract
Background
The scheduling of mastectomy with immediate reconstruction (M-IR) procedures requires coordination between breast and plastic surgical teams that can contribute to delays in breast cancer treatment and subsequently impact patient outcomes and satisfaction. The breast center leadership at our comprehensive cancer center established a time-to-treatment target of 28 days from initial consultation with a breast surgical oncologist to M-IR. We sought to determine if a centralized breast surgical coordinator (BC) could reduce preoperative delays.
Methods
We initiated a 60-day pilot program to evaluate the impact of a BC on the workflow, efficiency, and timeliness for patients seen at our breast center. All reconstructive surgery candidates were referred to the BC, who had access to the clinic and operating room schedules of the breast and plastic surgeons. The BC worked with patients and both surgical services to identify the earliest consult and surgery dates and facilitated case booking. Interval days between initial surgical consult and M-IR were calculated. The median time to M-IR and the proportion of M-IR cases that met the time-to-treatment goal was determined. These results were compared to a reference cohort of breast cancer patients undergoing M-IR during the same time period (January-March) in 2013 and 2014, who had their consults and surgeries scheduled independently by breast surgery administrative staff. Patients who received neoadjuvant therapy or did not have a definitive cancer diagnosis at initial consultation were excluded from the time-to-treatment calculation.
Results
A total of 99 patients were referred to the BC (62% cancer, 21% neoadjuvant, and 17% prophylactic) during the pilot period. Focusing exclusively on patients with a definitive breast cancer diagnosis at initial consultation, an 18.5% increase in the percentage of cases that met the target (p=0.04), and a 7 day decrease in the median number of days to M-IR (p=0.02) was observed with the implementation of the BC (Table 1).
Table 1: Days to M-IR Pre and Post Implementation of BCPatients (N)Median Days to M-IR (IQR)% M-IR within 28 daysBaseline (59)40.0 (17.0)23.7%BC (45)33.0 (20.0)42.2%p-value0.020.04
Conclusion
The coordination of care between breast surgical and reconstructive services presents timeliness challenges which may be partially alleviated through the implementation of a BC role. Establishing a centralized position to coordinate co-surgeon cases has improved time-to-treatment for M-IR at our cancer center. Further research is warranted to validate these preliminary findings, and determine the impact the BC has on operational efficiency and workflows.
Citation Format: Losk K, Mallory M, Caterson S, Camuso K, Cutone L, Roberts P, Lin N, Bunnell C, Golshan M. Implementation of a breast/reconstructive surgery coordinator to reduce preoperative delays for patients undergoing mastectomy with immediate reconstruction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-12.
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Affiliation(s)
- K Losk
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - M Mallory
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - S Caterson
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - K Camuso
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - L Cutone
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - P Roberts
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - N Lin
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - C Bunnell
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - M Golshan
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
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Blocker O, Abdulkadir U, Roberts P. Clostridium difficile-associated diarrhoea in primary joint arthroplasty in Aneurin Bevan University Health Board South. Ann R Coll Surg Engl 2016; 98:222-5. [PMID: 26836055 DOI: 10.1308/rcsann.2016.0066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION The choice of perioperative antibiotics to reduce the prevalence of infection after joint arthroplasty should be considered carefully to minimise the risk of nosocomial infections. Dramatic increases in the incidence and severity of healthcare-associated Clostridium difficile infection with Clostridium difficile-associated diarrhoea (CDAD) have occurred since 2000. METHODS A retrospective audit of patients who underwent total hip and total knee replacement between 1 January 2005 and 31 December 2007 was undertaken in Aneurin Bevan University Health Board South (ABHBS). Stool samples from patients who had diarrhoea <12 months of surgery were recorded. Positive samples for CDAD <1 month of surgery were identified. After the change in practice in June 2010, a re-audit linked joint-replacement patients between 1 July 2010 and 26 June 2013 with infection control-records for CDAD-positive cases. RESULTS In the first audit cycle, 1900 joint procedures were carried out in 1845 patients. There were 4 cases of CDAD <1 month of surgery (0.22%). In the re-audit period, 2591 joint procedures were undertaken in 2400 patients: no cases of CDAD <1 month of surgery were recorded. Fisher's exact test gave a two-tailed p=0.036. CONCLUSIONS The significant reduction in CDAD cases after the change in perioperative antibiotic regimen for primary joint arthroplasty mirrored a 66% reduction in overall CDAD cases in the ABUHBS between 2008 and 2012. This reduction was accompanied by financial savings in antibiotics and nursing hours.
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Affiliation(s)
- O Blocker
- Royal Gwent Hospital , Newport , Wales
| | | | - P Roberts
- Royal Gwent Hospital , Newport , Wales
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Foster A, Jones DL, Cooper EJ, Roberts P. Freeze-thaw cycles have minimal effect on the mineralisation of low molecular weight, dissolved organic carbon in Arctic soils. Polar Biol 2016; 39:2387-2401. [PMID: 32669755 PMCID: PMC7346978 DOI: 10.1007/s00300-016-1914-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 01/23/2016] [Accepted: 02/26/2016] [Indexed: 12/04/2022]
Abstract
Warmer winters in Arctic regions may melt insulating snow cover and subject soils to more freeze–thaw cycles. The effect of freeze–thaw cycles on the microbial use of low molecular weight, dissolved organic carbon (LMW-DOC) is poorly understood. In this study, soils from the Arctic heath tundra, Arctic meadow tundra and a temperate grassland were frozen to −7.5 °C and thawed once and three times. Subsequently, the mineralisation of 3 LMW-DOC substrates types (sugars, amino acids and peptides) was measured over an 8-day period and compared to controls which had not been frozen. This allowed the comparison of freeze–thaw effects between Arctic and temperate soil and between different substrates. The results showed that freeze–thaw cycles had no significant effect on C mineralisation in the Arctic tundra soils. In contrast, for the same intensity freeze–thaw cycles, a significant effect on C mineralisation was observed for all substrate types in the temperate soil although the response was substrate specific. Peptide and amino acid mineralisation were similarly affected by FT, whilst glucose had a different response. Further work is required to fully understand microbial use of LMW-DOC after freeze–thaw, yet these results suggest that relatively short freeze–thaw cycles have little effect on microbial use of LMW-DOC in Arctic tundra soils after thaw.
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Affiliation(s)
- A Foster
- School of the Environment, Natural Resources and Geography, Bangor University, Bangor, UK
| | - D L Jones
- School of the Environment, Natural Resources and Geography, Bangor University, Bangor, UK
| | - E J Cooper
- Department of Arctic and Marine Biology, Faculty of Biosciences, Fisheries and Economics, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - P Roberts
- School of the Environment, Natural Resources and Geography, Bangor University, Bangor, UK
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Beavers, Davie A, Zhou S, Roberts P. Blood pressure responses to immersion and hypertension – A consideration for water exercise. J Sci Med Sport 2015. [DOI: 10.1016/j.jsams.2015.12.491] [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: 10/22/2022]
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Affiliation(s)
- R. Rayner
- School of Nursing and Midwifery, Curtin University and Silver Chain Group, Western Australia
| | - K. Carville
- School of Nursing and Midwifery, Curtin University and Silver Chain Group, Western Australia
| | - G. Leslie
- School of Nursing and Midwifery, Curtin University, Western Australia
| | - P. Roberts
- School of Nursing and Midwifery, Curtin University, Western Australia
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Cohen K, Tzika A, Wood H, Berri S, Roberts P, Mason G, Sheridan E. Diagnosis of fetal submicroscopic chromosomal abnormalities in failed array CGH samples: copy number by sequencing as an alternative to microarrays for invasive fetal testing. Ultrasound Obstet Gynecol 2015; 45:394-401. [PMID: 25510919 DOI: 10.1002/uog.14767] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 11/11/2014] [Accepted: 12/10/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Array comparative genomic hybridization (CGH) has become the technology of choice for high-resolution prenatal whole genome analysis. Limitations of microarrays are mainly related to the analog nature of the analysis, and poor-quality DNA can result in failed quality metrics with these platforms. We examined a cohort of abnormal fetuses with failed array CGH results using a next-generation sequencing algorithm, CNV-Seq. We assessed the ability of the platform to handle suboptimal prenatal samples and generate interpretable molecular karyotypes. METHODS Nine samples obtained from abnormal fetuses and one from a normal control fetus were sequenced using an Illumina GAIIx. A segmentation algorithm for sequencing data was used to determine regional copy number data on the sequencing datasets. RESULTS Phred quality scores were satisfactory for analysis of all samples. CNV-Seq identified both large- and small-scale abnormalities in the cohort, and normal results were obtained for fetuses for which microarray data were previously uninterpretable. No variants of uncertain significance were detected. Analysis of the digital sequencing datasets offered some advantages over array CGH output. CONCLUSIONS Using next-generation sequencing for the detection of genomic copy number variants may be advantageous for poor-quality, invasively-acquired prenatal samples. CNV-Seq could become a potential alternative to array CGH in this setting.
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Affiliation(s)
- K Cohen
- Department of Fetal Medicine, Leeds General Infirmary, Leeds, UK; Leeds Institute of Cancer and Pathology, Leeds, UK
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Fitzgerald TW, Gerety SS, Jones WD, van Kogelenberg M, King DA, McRae J, Morley KI, Parthiban V, Al-Turki S, Ambridge K, Barrett DM, Bayzetinova T, Clayton S, Coomber EL, Gribble S, Jones P, Krishnappa N, Mason LE, Middleton A, Miller R, Prigmore E, Rajan D, Sifrim A, Tivey AR, Ahmed M, Akawi N, Andrews R, Anjum U, Archer H, Armstrong R, Balasubramanian M, Banerjee R, Baralle D, Batstone P, Baty D, Bennett C, Berg J, Bernhard B, Bevan AP, Blair E, Blyth M, Bohanna D, Bourdon L, Bourn D, Brady A, Bragin E, Brewer C, Brueton L, Brunstrom K, Bumpstead SJ, Bunyan DJ, Burn J, Burton J, Canham N, Castle B, Chandler K, Clasper S, Clayton-Smith J, Cole T, Collins A, Collinson MN, Connell F, Cooper N, Cox H, Cresswell L, Cross G, Crow Y, D’Alessandro M, Dabir T, Davidson R, Davies S, Dean J, Deshpande C, Devlin G, Dixit A, Dominiczak A, Donnelly C, Donnelly D, Douglas A, Duncan A, Eason J, Edkins S, Ellard S, Ellis P, Elmslie F, Evans K, Everest S, Fendick T, Fisher R, Flinter F, Foulds N, Fryer A, Fu B, Gardiner C, Gaunt L, Ghali N, Gibbons R, Gomes Pereira SL, Goodship J, Goudie D, Gray E, Greene P, Greenhalgh L, Harrison L, Hawkins R, Hellens S, Henderson A, Hobson E, Holden S, Holder S, Hollingsworth G, Homfray T, Humphreys M, Hurst J, Ingram S, Irving M, Jarvis J, Jenkins L, Johnson D, Jones D, Jones E, Josifova D, Joss S, Kaemba B, Kazembe S, Kerr B, Kini U, Kinning E, Kirby G, Kirk C, Kivuva E, Kraus A, Kumar D, Lachlan K, Lam W, Lampe A, Langman C, Lees M, Lim D, Lowther G, Lynch SA, Magee A, Maher E, Mansour S, Marks K, Martin K, Maye U, McCann E, McConnell V, McEntagart M, McGowan R, McKay K, McKee S, McMullan DJ, McNerlan S, Mehta S, Metcalfe K, Miles E, Mohammed S, Montgomery T, Moore D, Morgan S, Morris A, Morton J, Mugalaasi H, Murday V, Nevitt L, Newbury-Ecob R, Norman A, O'Shea R, Ogilvie C, Park S, Parker MJ, Patel C, Paterson J, Payne S, Phipps J, Pilz DT, Porteous D, Pratt N, Prescott K, Price S, Pridham A, Procter A, Purnell H, Ragge N, Rankin J, Raymond L, Rice D, Robert L, Roberts E, Roberts G, Roberts J, Roberts P, Ross A, Rosser E, Saggar A, Samant S, Sandford R, Sarkar A, Schweiger S, Scott C, Scott R, Selby A, Seller A, Sequeira C, Shannon N, Sharif S, Shaw-Smith C, Shearing E, Shears D, Simonic I, Simpkin D, Singzon R, Skitt Z, Smith A, Smith B, Smith K, Smithson S, Sneddon L, Splitt M, Squires M, Stewart F, Stewart H, Suri M, Sutton V, Swaminathan GJ, Sweeney E, Tatton-Brown K, Taylor C, Taylor R, Tein M, Temple IK, Thomson J, Tolmie J, Torokwa A, Treacy B, Turner C, Turnpenny P, Tysoe C, Vandersteen A, Vasudevan P, Vogt J, Wakeling E, Walker D, Waters J, Weber A, Wellesley D, Whiteford M, Widaa S, Wilcox S, Williams D, Williams N, Woods G, Wragg C, Wright M, Yang F, Yau M, Carter NP, Parker M, Firth HV, FitzPatrick DR, Wright CF, Barrett JC, Hurles ME. Large-scale discovery of novel genetic causes of developmental disorders. Nature 2015; 519:223-8. [PMID: 25533962 PMCID: PMC5955210 DOI: 10.1038/nature14135] [Citation(s) in RCA: 773] [Impact Index Per Article: 85.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 12/04/2014] [Indexed: 12/23/2022]
Abstract
Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.
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Affiliation(s)
- TW Fitzgerald
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - SS Gerety
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - WD Jones
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - M van Kogelenberg
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - DA King
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - J McRae
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - KI Morley
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - V Parthiban
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - S Al-Turki
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - K Ambridge
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - DM Barrett
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - T Bayzetinova
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - S Clayton
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - EL Coomber
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - S Gribble
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - P Jones
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - N Krishnappa
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - LE Mason
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - A Middleton
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - R Miller
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - E Prigmore
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - D Rajan
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - A Sifrim
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - AR Tivey
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - M Ahmed
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - N Akawi
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - R Andrews
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - U Anjum
- South West Thames Regional Genetics Centre, St George’s Healthcare NHS Trust, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - H Archer
- Institute Of Medical Genetics, University Hospital Of Wales, Heath Park, Cardiff, CF14 4XW, UK and Department of Clinical Genetics, Block 12, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - R Armstrong
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - M Balasubramanian
- Sheffield Regional Genetics Services, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - R Banerjee
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - D Baralle
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - P Batstone
- North of Scotland Regional Genetics Service, NHS Grampian, Department of Medical Genetics Medical School, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - D Baty
- East of Scotland Regional Genetics Service, Human Genetics Unit, Pathology Department, NHS Tayside, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - C Bennett
- Yorkshire Regional Genetics Service, Leeds Teaching Hospitals NHS Trust, Department of Clinical Genetics, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - J Berg
- East of Scotland Regional Genetics Service, Human Genetics Unit, Pathology Department, NHS Tayside, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - B Bernhard
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - AP Bevan
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - E Blair
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - M Blyth
- Yorkshire Regional Genetics Service, Leeds Teaching Hospitals NHS Trust, Department of Clinical Genetics, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - D Bohanna
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - L Bourdon
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - D Bourn
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - A Brady
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - E Bragin
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - C Brewer
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - L Brueton
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - K Brunstrom
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - SJ Bumpstead
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - DJ Bunyan
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - J Burn
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - J Burton
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - N Canham
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - B Castle
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - K Chandler
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL
| | - S Clasper
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - J Clayton-Smith
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL
| | - T Cole
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - A Collins
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - MN Collinson
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - F Connell
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - N Cooper
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - H Cox
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - L Cresswell
- Leicestershire Genetics Centre, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary (NHS Trust), Leicester, LE1 5WW, UK
| | - G Cross
- Nottingham Regional Genetics Service, City Hospital Campus, Nottingham University Hospitals NHS Trust, The Gables, Hucknall Road, Nottingham NG5 1PB, UK
| | - Y Crow
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL
| | - M D’Alessandro
- North of Scotland Regional Genetics Service, NHS Grampian, Department of Medical Genetics Medical School, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - T Dabir
- Northern Ireland Regional Genetics Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - R Davidson
- West of Scotland Regional Genetics Service, NHS Greater Glasgow and Clyde, Institute Of Medical Genetics, Yorkhill Hospital, Glasgow, G3 8SJ, UK
| | - S Davies
- Institute Of Medical Genetics, University Hospital Of Wales, Heath Park, Cardiff, CF14 4XW, UK and Department of Clinical Genetics, Block 12, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - J Dean
- North of Scotland Regional Genetics Service, NHS Grampian, Department of Medical Genetics Medical School, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - C Deshpande
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - G Devlin
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - A Dixit
- Nottingham Regional Genetics Service, City Hospital Campus, Nottingham University Hospitals NHS Trust, The Gables, Hucknall Road, Nottingham NG5 1PB, UK
| | - A Dominiczak
- University of Edinburgh, Institute of Genetics & Molecular Medicine, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, UK
| | - C Donnelly
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL
| | - D Donnelly
- Northern Ireland Regional Genetics Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - A Douglas
- Merseyside and Cheshire Genetics Service, Liverpool Women’s NHS Foundation Trust, Department of Clinical Genetics, Royal Liverpool Children’s Hospital Alder Hey, Eaton Road, Liverpool, L12 2AP, UK
| | - A Duncan
- West of Scotland Regional Genetics Service, NHS Greater Glasgow and Clyde, Institute Of Medical Genetics, Yorkhill Hospital, Glasgow, G3 8SJ, UK
| | - J Eason
- Nottingham Regional Genetics Service, City Hospital Campus, Nottingham University Hospitals NHS Trust, The Gables, Hucknall Road, Nottingham NG5 1PB, UK
| | - S Edkins
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - S Ellard
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - P Ellis
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - F Elmslie
- South West Thames Regional Genetics Centre, St George’s Healthcare NHS Trust, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - K Evans
- Institute Of Medical Genetics, University Hospital Of Wales, Heath Park, Cardiff, CF14 4XW, UK and Department of Clinical Genetics, Block 12, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - S Everest
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - T Fendick
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - R Fisher
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - F Flinter
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - N Foulds
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - A Fryer
- Merseyside and Cheshire Genetics Service, Liverpool Women’s NHS Foundation Trust, Department of Clinical Genetics, Royal Liverpool Children’s Hospital Alder Hey, Eaton Road, Liverpool, L12 2AP, UK
| | - B Fu
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - C Gardiner
- West of Scotland Regional Genetics Service, NHS Greater Glasgow and Clyde, Institute Of Medical Genetics, Yorkhill Hospital, Glasgow, G3 8SJ, UK
| | - L Gaunt
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL
| | - N Ghali
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - R Gibbons
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - SL Gomes Pereira
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - J Goodship
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - D Goudie
- East of Scotland Regional Genetics Service, Human Genetics Unit, Pathology Department, NHS Tayside, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - E Gray
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - P Greene
- MRC Human Genetics Unit, MRC IGMM, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - L Greenhalgh
- Merseyside and Cheshire Genetics Service, Liverpool Women’s NHS Foundation Trust, Department of Clinical Genetics, Royal Liverpool Children’s Hospital Alder Hey, Eaton Road, Liverpool, L12 2AP, UK
| | - L Harrison
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - R Hawkins
- Bristol Genetics Service (Avon, Somerset, Gloucs and West Wilts), University Hospitals Bristol NHS Foundation Trust, St Michael’s Hospital, St Michael’s Hill, Bristol, BS2 8DT, UK
| | - S Hellens
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - A Henderson
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - E Hobson
- Yorkshire Regional Genetics Service, Leeds Teaching Hospitals NHS Trust, Department of Clinical Genetics, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - S Holden
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - S Holder
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - G Hollingsworth
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - T Homfray
- South West Thames Regional Genetics Centre, St George’s Healthcare NHS Trust, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - M Humphreys
- Northern Ireland Regional Genetics Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - J Hurst
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - S Ingram
- Sheffield Regional Genetics Services, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - M Irving
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - J Jarvis
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - L Jenkins
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - D Johnson
- Sheffield Regional Genetics Services, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - D Jones
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - E Jones
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL
| | - D Josifova
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - S Joss
- West of Scotland Regional Genetics Service, NHS Greater Glasgow and Clyde, Institute Of Medical Genetics, Yorkhill Hospital, Glasgow, G3 8SJ, UK
| | - B Kaemba
- Leicestershire Genetics Centre, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary (NHS Trust), Leicester, LE1 5WW, UK
| | - S Kazembe
- Leicestershire Genetics Centre, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary (NHS Trust), Leicester, LE1 5WW, UK
| | - B Kerr
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL
| | - U Kini
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - E Kinning
- West of Scotland Regional Genetics Service, NHS Greater Glasgow and Clyde, Institute Of Medical Genetics, Yorkhill Hospital, Glasgow, G3 8SJ, UK
| | - G Kirby
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - C Kirk
- Northern Ireland Regional Genetics Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - E Kivuva
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - A Kraus
- Yorkshire Regional Genetics Service, Leeds Teaching Hospitals NHS Trust, Department of Clinical Genetics, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - D Kumar
- Institute Of Medical Genetics, University Hospital Of Wales, Heath Park, Cardiff, CF14 4XW, UK and Department of Clinical Genetics, Block 12, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - K Lachlan
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - W Lam
- MRC Human Genetics Unit, MRC IGMM, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - A Lampe
- MRC Human Genetics Unit, MRC IGMM, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - C Langman
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - M Lees
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - D Lim
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - G Lowther
- West of Scotland Regional Genetics Service, NHS Greater Glasgow and Clyde, Institute Of Medical Genetics, Yorkhill Hospital, Glasgow, G3 8SJ, UK
| | - SA Lynch
- National Centre for Medical Genetics, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland
| | - A Magee
- Northern Ireland Regional Genetics Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - E Maher
- MRC Human Genetics Unit, MRC IGMM, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - S Mansour
- South West Thames Regional Genetics Centre, St George’s Healthcare NHS Trust, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - K Marks
- South West Thames Regional Genetics Centre, St George’s Healthcare NHS Trust, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - K Martin
- Nottingham Regional Genetics Service, City Hospital Campus, Nottingham University Hospitals NHS Trust, The Gables, Hucknall Road, Nottingham NG5 1PB, UK
| | - U Maye
- Merseyside and Cheshire Genetics Service, Liverpool Women’s NHS Foundation Trust, Department of Clinical Genetics, Royal Liverpool Children’s Hospital Alder Hey, Eaton Road, Liverpool, L12 2AP, UK
| | - E McCann
- Institute Of Medical Genetics, University Hospital Of Wales, Heath Park, Cardiff, CF14 4XW, UK and Department of Clinical Genetics, Block 12, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - V McConnell
- Northern Ireland Regional Genetics Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - M McEntagart
- South West Thames Regional Genetics Centre, St George’s Healthcare NHS Trust, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - R McGowan
- North of Scotland Regional Genetics Service, NHS Grampian, Department of Medical Genetics Medical School, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - K McKay
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - S McKee
- Northern Ireland Regional Genetics Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - DJ McMullan
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - S McNerlan
- Northern Ireland Regional Genetics Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - S Mehta
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - K Metcalfe
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL
| | - E Miles
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL
| | - S Mohammed
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - T Montgomery
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - D Moore
- MRC Human Genetics Unit, MRC IGMM, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - S Morgan
- Institute Of Medical Genetics, University Hospital Of Wales, Heath Park, Cardiff, CF14 4XW, UK and Department of Clinical Genetics, Block 12, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - A Morris
- University of Edinburgh, Institute of Genetics & Molecular Medicine, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, UK
| | - J Morton
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - H Mugalaasi
- Institute Of Medical Genetics, University Hospital Of Wales, Heath Park, Cardiff, CF14 4XW, UK and Department of Clinical Genetics, Block 12, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - V Murday
- West of Scotland Regional Genetics Service, NHS Greater Glasgow and Clyde, Institute Of Medical Genetics, Yorkhill Hospital, Glasgow, G3 8SJ, UK
| | - L Nevitt
- Sheffield Regional Genetics Services, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - R Newbury-Ecob
- Bristol Genetics Service (Avon, Somerset, Gloucs and West Wilts), University Hospitals Bristol NHS Foundation Trust, St Michael’s Hospital, St Michael’s Hill, Bristol, BS2 8DT, UK
| | - A Norman
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - R O'Shea
- National Centre for Medical Genetics, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland
| | - C Ogilvie
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - S Park
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - MJ Parker
- Sheffield Regional Genetics Services, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - C Patel
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - J Paterson
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - S Payne
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - J Phipps
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - DT Pilz
- Institute Of Medical Genetics, University Hospital Of Wales, Heath Park, Cardiff, CF14 4XW, UK and Department of Clinical Genetics, Block 12, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - D Porteous
- University of Edinburgh, Institute of Genetics & Molecular Medicine, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, UK
| | - N Pratt
- East of Scotland Regional Genetics Service, Human Genetics Unit, Pathology Department, NHS Tayside, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - K Prescott
- Yorkshire Regional Genetics Service, Leeds Teaching Hospitals NHS Trust, Department of Clinical Genetics, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - S Price
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - A Pridham
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - A Procter
- Institute Of Medical Genetics, University Hospital Of Wales, Heath Park, Cardiff, CF14 4XW, UK and Department of Clinical Genetics, Block 12, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - H Purnell
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - N Ragge
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - J Rankin
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - L Raymond
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - D Rice
- East of Scotland Regional Genetics Service, Human Genetics Unit, Pathology Department, NHS Tayside, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - L Robert
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - E Roberts
- Bristol Genetics Service (Avon, Somerset, Gloucs and West Wilts), University Hospitals Bristol NHS Foundation Trust, St Michael’s Hospital, St Michael’s Hill, Bristol, BS2 8DT, UK
| | - G Roberts
- Merseyside and Cheshire Genetics Service, Liverpool Women’s NHS Foundation Trust, Department of Clinical Genetics, Royal Liverpool Children’s Hospital Alder Hey, Eaton Road, Liverpool, L12 2AP, UK
| | - J Roberts
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - P Roberts
- Yorkshire Regional Genetics Service, Leeds Teaching Hospitals NHS Trust, Department of Clinical Genetics, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - A Ross
- North of Scotland Regional Genetics Service, NHS Grampian, Department of Medical Genetics Medical School, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - E Rosser
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - A Saggar
- South West Thames Regional Genetics Centre, St George’s Healthcare NHS Trust, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - S Samant
- North of Scotland Regional Genetics Service, NHS Grampian, Department of Medical Genetics Medical School, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - R Sandford
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - A Sarkar
- Nottingham Regional Genetics Service, City Hospital Campus, Nottingham University Hospitals NHS Trust, The Gables, Hucknall Road, Nottingham NG5 1PB, UK
| | - S Schweiger
- East of Scotland Regional Genetics Service, Human Genetics Unit, Pathology Department, NHS Tayside, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - C Scott
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - R Scott
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - A Selby
- Nottingham Regional Genetics Service, City Hospital Campus, Nottingham University Hospitals NHS Trust, The Gables, Hucknall Road, Nottingham NG5 1PB, UK
| | - A Seller
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - C Sequeira
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - N Shannon
- Nottingham Regional Genetics Service, City Hospital Campus, Nottingham University Hospitals NHS Trust, The Gables, Hucknall Road, Nottingham NG5 1PB, UK
| | - S Sharif
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - C Shaw-Smith
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - E Shearing
- Sheffield Regional Genetics Services, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - D Shears
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - I Simonic
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - D Simpkin
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - R Singzon
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - Z Skitt
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL
| | - A Smith
- Yorkshire Regional Genetics Service, Leeds Teaching Hospitals NHS Trust, Department of Clinical Genetics, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - B Smith
- University of Edinburgh, Institute of Genetics & Molecular Medicine, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, UK
| | - K Smith
- Sheffield Regional Genetics Services, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - S Smithson
- Bristol Genetics Service (Avon, Somerset, Gloucs and West Wilts), University Hospitals Bristol NHS Foundation Trust, St Michael’s Hospital, St Michael’s Hill, Bristol, BS2 8DT, UK
| | - L Sneddon
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - M Splitt
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - M Squires
- Yorkshire Regional Genetics Service, Leeds Teaching Hospitals NHS Trust, Department of Clinical Genetics, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - F Stewart
- Northern Ireland Regional Genetics Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - H Stewart
- Oxford Regional Genetics Service, Oxford Radcliffe Hospitals NHS Trust, The Churchill Old Road, Oxford, OX3 7LJ, UK
| | - M Suri
- Nottingham Regional Genetics Service, City Hospital Campus, Nottingham University Hospitals NHS Trust, The Gables, Hucknall Road, Nottingham NG5 1PB, UK
| | - V Sutton
- Merseyside and Cheshire Genetics Service, Liverpool Women’s NHS Foundation Trust, Department of Clinical Genetics, Royal Liverpool Children’s Hospital Alder Hey, Eaton Road, Liverpool, L12 2AP, UK
| | - GJ Swaminathan
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - E Sweeney
- Merseyside and Cheshire Genetics Service, Liverpool Women’s NHS Foundation Trust, Department of Clinical Genetics, Royal Liverpool Children’s Hospital Alder Hey, Eaton Road, Liverpool, L12 2AP, UK
| | - K Tatton-Brown
- South West Thames Regional Genetics Centre, St George’s Healthcare NHS Trust, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - C Taylor
- Sheffield Regional Genetics Services, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - R Taylor
- South West Thames Regional Genetics Centre, St George’s Healthcare NHS Trust, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - M Tein
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - IK Temple
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - J Thomson
- Yorkshire Regional Genetics Service, Leeds Teaching Hospitals NHS Trust, Department of Clinical Genetics, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - J Tolmie
- West of Scotland Regional Genetics Service, NHS Greater Glasgow and Clyde, Institute Of Medical Genetics, Yorkhill Hospital, Glasgow, G3 8SJ, UK
| | - A Torokwa
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - B Treacy
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - C Turner
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - P Turnpenny
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - C Tysoe
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Clinical Genetics Department, Royal Devon & Exeter Hospital (Heavitree), Gladstone Road, Exeter, EX1 2ED, UK
| | - A Vandersteen
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - P Vasudevan
- Leicestershire Genetics Centre, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary (NHS Trust), Leicester, LE1 5WW, UK
| | - J Vogt
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - E Wakeling
- North West Thames Regional Genetics Centre, North West London Hospitals NHS Trust, The Kennedy Galton Centre, Northwick Park And St Mark’s NHS Trust Watford Road, Harrow, HA1 3UJ, UK
| | - D Walker
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - J Waters
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - A Weber
- Merseyside and Cheshire Genetics Service, Liverpool Women’s NHS Foundation Trust, Department of Clinical Genetics, Royal Liverpool Children’s Hospital Alder Hey, Eaton Road, Liverpool, L12 2AP, UK
| | - D Wellesley
- Wessex Clinical Genetics Service, University Hospital Southampton, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK and Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK and Faculty of Medicine, University of Southampton
| | - M Whiteford
- West of Scotland Regional Genetics Service, NHS Greater Glasgow and Clyde, Institute Of Medical Genetics, Yorkhill Hospital, Glasgow, G3 8SJ, UK
| | - S Widaa
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - S Wilcox
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - D Williams
- West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK
| | - N Williams
- West of Scotland Regional Genetics Service, NHS Greater Glasgow and Clyde, Institute Of Medical Genetics, Yorkhill Hospital, Glasgow, G3 8SJ, UK
| | - G Woods
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - C Wragg
- Bristol Genetics Service (Avon, Somerset, Gloucs and West Wilts), University Hospitals Bristol NHS Foundation Trust, St Michael’s Hospital, St Michael’s Hill, Bristol, BS2 8DT, UK
| | - M Wright
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - F Yang
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - M Yau
- South East Thames Regional Genetics Centre, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - NP Carter
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - M Parker
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - HV Firth
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
- East Anglian Medical Genetics Service, Box 134, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - DR FitzPatrick
- MRC Human Genetics Unit, MRC IGMM, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - CF Wright
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - JC Barrett
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - ME Hurles
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
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Bray J, Ekers R, Roberts P, Reynolds J, James C, Phillips C, Protheroe R, McFadden R, Aartsen M. Limit on the ultrahigh-energy neutrino flux from lunar observations with the Parkes radio telescope. Int J Clin Exp Med 2015. [DOI: 10.1103/physrevd.91.063002] [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: 11/07/2022]
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Tsai J, Occleshaw C, Roberts P, Lydon A, Shannhan C, Edwards K, Oliver G, Harrod M, Cowan B, Young A, Wasywich C. MRI-augmented right heart catheterization: a pilot study. Heart Lung Circ 2015. [DOI: 10.1016/j.hlc.2015.04.078] [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: 10/23/2022]
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Mathew RK, Goacher E, Bhargava D, Chakrabarty A, Roberts P, Goodden J, Loughrey C, Chumas PD. P68 * UNRAVELLING GRADE 3 GLIOMAS. Neuro Oncol 2014. [DOI: 10.1093/neuonc/nou249.54] [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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Mathew R, Goacher E, Bhargava D, Chakrabarty A, Roberts P, Goodden J, Loughrey C, Chumas P. P17.55 * UNRAVELLING GRADE 3 GLIOMAS. Neuro Oncol 2014. [DOI: 10.1093/neuonc/nou174.384] [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: 11/12/2022] Open
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McCready J, Chow AW, Lowe MD, Segal OR, Ahsan S, de Bono J, Dhaliwal M, Mfuko C, Ng A, Rowland ER, Bradley RJW, Paisey J, Roberts P, Morgan JM, Sandilands A, Yue A, Lambiase PD. Safety and efficacy of multipolar pulmonary vein ablation catheter vs. irrigated radiofrequency ablation for paroxysmal atrial fibrillation: a randomized multicentre trial. Europace 2014; 16:1145-53. [PMID: 24843051 PMCID: PMC4114331 DOI: 10.1093/europace/euu064] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Aims The current challenge in atrial fibrillation (AF) treatment is to develop effective, efficient, and safe ablation strategies. This randomized controlled trial assesses the medium-term efficacy of duty-cycled radiofrequency ablation via the circular pulmonary vein ablation catheter (PVAC) vs. conventional electro-anatomically guided wide-area circumferential ablation (WACA). Methods and results One hundred and eighty-eight patients (mean age 62 ± 12 years, 116 M : 72 F) with paroxysmal AF were prospectively randomized to PVAC or WACA strategies and sequentially followed for 12 months. The primary endpoint was freedom from symptomatic or documented >30 s AF off medications for 7 days at 12 months post-procedure. One hundred and eighty-three patients completed 12 m follow-up. Ninety-four patients underwent PVAC PV isolation with 372 of 376 pulmonary veins (PVs) successfully isolated and all PVs isolated in 92 WACA patients. Three WACA and no PVAC patients developed tamponade. Fifty-six percent of WACA and 60% of PVAC patients were free of AF at 12 months post-procedure (P = ns) with a significant attrition rate from 77 to 78%, respectively, at 6 months. The mean procedure (140 ± 43 vs. 167 ± 42 min, P<0.0001), fluoroscopy (35 ± 16 vs. 42 ± 20 min, P<0.05) times were significantly shorter for PVAC than for WACA. Two patients developed strokes within 72 h of the procedure in the PVAC group, one possibly related directly to PVAC ablation in a high-risk patient and none in the WACA group (P = ns). Two of the 47 patients in the PVAC group who underwent repeat ablation had sub-clinical mild PV stenoses of 25–50% and 1 WACA patient developed delayed severe PV stenosis requiring venoplasty. Conclusion The pulmonary vein ablation catheter is equivalent in efficacy to WACA with reduced procedural and fluoroscopy times. However, there is a risk of thrombo-embolic and pulmonary stenosis complications which needs to be addressed and prospectively monitored. ClinicalTrials.gov Identifier NCT00678340.
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Affiliation(s)
- J McCready
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - A W Chow
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - M D Lowe
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - O R Segal
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - S Ahsan
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - J de Bono
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - M Dhaliwal
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - C Mfuko
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - A Ng
- Cardiology Department, Glenfield Heart Centre, Leicester, Leicestershire LE39QP, UK
| | - E R Rowland
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - R J W Bradley
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - J Paisey
- Cardiology Department, Royal Bournemouth Hospital Castle Lane East Bournemouth, Bournemouth BH7 7DW, UK
| | - P Roberts
- Cardiology Department, Southampton General Hospital, Southampton, Hampshire SO16 6YD, UK
| | - J M Morgan
- Cardiology Department, Southampton General Hospital, Southampton, Hampshire SO16 6YD, UK
| | - A Sandilands
- Cardiology Department, Glenfield Heart Centre, Leicester, Leicestershire LE39QP, UK
| | - A Yue
- Cardiology Department, Southampton General Hospital, Southampton, Hampshire SO16 6YD, UK
| | - P D Lambiase
- Cardiology Department, The Heart Hospital, University College Hospital and Institute of Cardiovascular Sciences, UCL, 16-18 Westmoreland Street, London W1G 8PH, UK
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Liu J, Ogden A, Comery TA, Spiros A, Roberts P, Geerts H. Prediction of Efficacy of Vabicaserin, a 5-HT2C Agonist, for the Treatment of Schizophrenia Using a Quantitative Systems Pharmacology Model. CPT Pharmacometrics Syst Pharmacol 2014; 3:e111. [PMID: 24759548 PMCID: PMC4011163 DOI: 10.1038/psp.2014.7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 02/06/2014] [Indexed: 01/12/2023]
Abstract
A quantitative systems pharmacology model that combines in vitro/preclinical neurophysiology data, human imaging data, and patient disease information was used to blindly predict steady-state clinical efficacy of vabicaserin, a 5-HT2C full agonist, in monotherapy and, subsequently, to assess adjunctive therapy in schizophrenia. The model predicted a concentration-dependent improvement of positive and negative syndrome scales (PANSS) in schizophrenia monotherapy with vabicaserin. At the exposures of 100 and 200 mg b.i.d., the predicted improvements on PANSS in virtual patient trials were 5.12 (2.20, 8.56) and 6.37 (2.27, 10.40) (mean (95% confidence interval)), respectively, which are comparable to the observed phase IIa results. At the current clinical exposure limit of vabicaserin, the model predicted an ~9-point PANSS improvement in monotherapy, and <4-point PANSS improvement adjunctive with various antipsychotics, suggesting limited clinical benefit of vabicaserin in schizophrenia treatment. In conclusion, the updated quantitative systems pharmacology model of PANSS informed the clinical development decision of vabicaserin in schizophrenia.
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Affiliation(s)
- J Liu
- Clinical Pharmacology, Pfizer, Groton, Connecticut, USA
| | - A Ogden
- Clinical Pharmacology, Pfizer, Groton, Connecticut, USA
| | - T A Comery
- Neuroscience Research Unit, Pfizer, Cambridge, Massachusetts, USA
| | - A Spiros
- In Silico Biosciences, Lexington, Massachusetts, USA
| | - P Roberts
- 1] In Silico Biosciences, Lexington, Massachusetts, USA [2] Oregon Health and Science University, Portland, Oregon, USA
| | - H Geerts
- 1] In Silico Biosciences, Lexington, Massachusetts, USA [2] Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Rayment M, Doku E, Thornton A, Pearn M, Sudhanva M, Jones R, Nardone A, Roberts P, Tenant-Flowers M, Anderson J, Sullivan AK, Atkins M. Automatic oral fluid-based HIV testing in HIV screening programmes: automatic for the people. HIV Med 2014; 14 Suppl 3:49-52. [PMID: 24033905 DOI: 10.1111/hiv.12063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVES UK guidelines recommend routine HIV testing in general clinical settings when the local HIV prevalence is > 0.2%. During pilot programmes evaluating the guidelines, we used laboratory-based testing of oral fluid from patients accepting tests. Samples (n = 3721) were tested manually using the Bio-Rad Genscreen Ultra HIV Ag-Ab test (Bio-Rad Laboratories Ltd, Hemel Hempstead, UK). This was a methodologically robust method, but handling of samples was labour intensive. We performed a validation study to ascertain whether automation of oral fluid HIV testing using the fourth-generation HIV test on the Abbott Architect (Abbott Diagnostics, Maidenhead, UK) platform was possible. METHODS Oral fluid was collected from 143 patients (56 known HIV-positive volunteers and 87 others having contemporaneous HIV serological tests) using the Oracol+ device (Malvern Medicals, Worcester, UK). Samples were tested concurrently: manually using the Genscreen Ultra test and automatically on the Abbott Architect. RESULTS For oral fluid, the level of agreement of results between the platforms was 100%. All results agreed with HIV serology. The use of the Oracol+ device produced high-quality samples. Subsequent field use of the test has shown a specificity of 99.97% after nearly 3000 tests. CONCLUSIONS Laboratory-based HIV testing of oral fluid requires less training of local staff, with fewer demands on clinical time and space than near-patient testing. It is acceptable to patients. The validation exercise and subsequent clinical experience support automation, with test performance preserved. Automation reduces laboratory workload and speeds up the release of results. Automated oral fluid testing is thus a viable option for large-scale HIV screening programmes.
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Affiliation(s)
- M Rayment
- Directorate of HIV/GU Medicine, Chelsea and Westminster Hospital NHS Foundation Trust
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44
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Rayment M, Rae C, Ghooloo F, Doku E, Hardie J, Finlay S, Gidwani S, Atkins M, Roberts P, Sullivan AK. Routine HIV testing in the emergency department: tough lessons in sustainability. HIV Med 2014; 14 Suppl 3:6-9. [PMID: 24033895 DOI: 10.1111/hiv.12069] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Routine HIV testing in nonspecialist settings has been shown to be acceptable to patients and staff in pilot studies. The question of how to embed routine HIV testing, and make it sustainable, remains to be answered. METHODS We established a service of routine HIV testing in an emergency department (ED) in London, delivered by ED staff as part of routine clinical care. All patients aged 16 to 65 years were offered an HIV test (latterly the upper age limit was removed). Meetings were held weekly and two outcome measures examined: test offer rate (coverage) and test uptake. Sustainability methodology (process mapping; plan-do-study-act (PDSA) cycles) was applied to maximize these outcome measures. RESULTS Over 30 months, 44,582 eligible patients attended the ED. The mean proportion offered an HIV test was 14%, varying from 6% to 54% per month over the testing period. The mean proportion accepting a test was 63% (range 33-100%). A total of 4327 HIV tests have been performed. Thirteen patients have been diagnosed with HIV infection (0.30%). PDSA cycles having the most positive and sustained effects on the outcome measures include the expansion to offer blood-based HIV tests in addition to the original oral fluid tests, and the engagement of ED nursing staff in the programme. CONCLUSIONS HIV testing can be delivered in the ED, but constant innovation and attention have been required to maintain it over 30 months. Patient uptake remains high, suggesting acceptability, but time will be required before true embedding in routine clinical practice is achieved.
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Affiliation(s)
- M Rayment
- Directorate of HIV/GU Medicine, Chelsea and Westminster Hospital NHS Foundation Trust
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45
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McDonald TO, Giardiello M, Martin P, Siccardi M, Liptrott NJ, Smith D, Roberts P, Curley P, Schipani A, Khoo SH, Long J, Foster AJ, Rannard SP, Owen A. Antiretroviral solid drug nanoparticles with enhanced oral bioavailability: production, characterization, and in vitro-in vivo correlation. Adv Healthc Mater 2014; 3:400-11. [PMID: 23997027 DOI: 10.1002/adhm.201300280] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Indexed: 01/11/2023]
Abstract
Nanomedicine strategies have produced many commercial products. However, no orally dosed HIV nanomedicines are available clinically to patients. Although nanosuspensions of drug particles have demonstrated many benefits, experimentally achieving >25 wt% of drug relative to stabilizers is highly challenging. In this study, the emulsion-templated freeze-drying technique for nanoparticles formation is applied for the first time to optimize a nanodispersion of the leading non-nucleoside reverse transcriptase inhibitor efavirenz, using clinically acceptable polymers and surfactants. Dry monoliths containing solid drug nanoparticles with extremely high drug loading (70 wt% relative to polymer and surfactant stabilizers) are stable for several months and reconstitute in aqueous media to provide nanodispersions with z-average diameters of 300 nm. The solid drug nanoparticles exhibit reduced cytoxicity and increased in vitro transport through model gut epithelium. In vivo studies confirm bioavailability benefits with an approximately four-fold higher pharmacokinetic exposure after oral administration to rodents, and predictive modeling suggests dose reduction with the new formulation may be possible.
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Affiliation(s)
- Tom O. McDonald
- Department of Chemistry; University of Liverpool; Crown Street L69 3BX UK
| | - Marco Giardiello
- Department of Chemistry; University of Liverpool; Crown Street L69 3BX UK
| | - Philip Martin
- Department of Molecular and Clinical Pharmacology; University of Liverpool; Block H, 70 Pembroke Place Liverpool L69 3GF UK
| | - Marco Siccardi
- Department of Molecular and Clinical Pharmacology; University of Liverpool; Block H, 70 Pembroke Place Liverpool L69 3GF UK
| | - Neill J. Liptrott
- Department of Molecular and Clinical Pharmacology; University of Liverpool; Block H, 70 Pembroke Place Liverpool L69 3GF UK
| | - Darren Smith
- Department of Molecular and Clinical Pharmacology; University of Liverpool; Block H, 70 Pembroke Place Liverpool L69 3GF UK
| | - Phill Roberts
- Department of Molecular and Clinical Pharmacology; University of Liverpool; Block H, 70 Pembroke Place Liverpool L69 3GF UK
| | - Paul Curley
- Department of Molecular and Clinical Pharmacology; University of Liverpool; Block H, 70 Pembroke Place Liverpool L69 3GF UK
| | - Alessandro Schipani
- Department of Molecular and Clinical Pharmacology; University of Liverpool; Block H, 70 Pembroke Place Liverpool L69 3GF UK
| | - Saye H. Khoo
- Department of Molecular and Clinical Pharmacology; University of Liverpool; Block H, 70 Pembroke Place Liverpool L69 3GF UK
| | - James Long
- IOTA NanoSolutions Ltd.; Crown Street Liverpool L69 7ZB UK
| | | | - Steven P. Rannard
- Department of Chemistry; University of Liverpool; Crown Street L69 3BX UK
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology; University of Liverpool; Block H, 70 Pembroke Place Liverpool L69 3GF UK
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Rankeillor KL, Cairns DA, Loughrey C, Short SC, Chumas P, Ismail A, Chakrabarty A, Lawler SE, Roberts P. Methylation-specific multiplex ligation-dependent probe amplification identifies promoter methylation events associated with survival in glioblastoma. J Neurooncol 2014; 117:243-51. [PMID: 24554053 DOI: 10.1007/s11060-014-1372-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [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: 01/08/2013] [Accepted: 01/18/2014] [Indexed: 12/22/2022]
Abstract
DNA methylation plays an important role in cancer biology and methylation events are important prognostic and predictive markers in many tumor types. We have used methylation-specific multiplex ligation-dependent probe amplification to survey the methylation status of MGMT and 25 tumor suppressor genes in 73 glioblastoma cases. The data obtained was correlated with overall survival and response to treatment. The study revealed that methylation of promoter regions in TP73 (seven patients), THBS1 (eight patients) and PYCARD (nine patients) was associated with improved outcome, whereas GATA5 (21 patients) and WT1 (24 patients) promoter methylation were associated with poor outcome. In patients treated with temozolomide and radiation MGMT and PYCARD promoter methylation events remained associated with improved survival whereas GATA5 was associated with a poor outcome. The identification of GATA5 promoter methylation in glioblastoma has not previously been reported. Furthermore, a cumulative methylation score separated patients into survival groups better than any single methylation event. In conclusion, we have identified specific methylation events associated with patient outcome and treatment response in glioblastoma, and these may be of functional and predictive/prognostic significance. This study therefore provides novel candidates and approaches for future prospective validation.
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Affiliation(s)
- K L Rankeillor
- Yorkshire Regional Cytogenetics Unit, St James's University Hospital, Leeds, LS9 7TF, UK,
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Fabritz L, Fortmuller L, Vloumidi E, Yue TY, Syeda F, Kirchhof P, Leube R, Krusche C, Chin SH, Winter J, Brack KE, Ng GA, Ng FS, Holzem KM, Koppel AC, Janks D, Wit AL, Peters NS, Efimov IR, Chowdhury RA, El-Harasis MA, Dupont E, Terracciano CMN, Peters NS, Mellor GJ, Raju H, de Noronha SV, Papadakis M, Sharma S, Behr ER, Sheppard MN, Jamil-Copley S, Bai W, Ariff B, Lim PB, Koa-Wing M, Kyriacou A, Hayat S, Sohaib A, Qureshi N, Sandler B, O'Regan D, Whinnett Z, Davies W, Rueckert D, Kanagaratnam P, Peters N, Lambiase PD, Chow AW, Lowe MD, Segal OR, Ahsan S, de Bono J, Dhaliwal M, Mfuko C, Ng A, Sandilands A, Paisey J, Roberts P, Morgan JM, McCready J, Yue A, Ullah W, Hunter R, Lovell M, Dhinoja M, Sporton S, Earley M, Schilling R, Ghosh J, Martin A, Keech A, Chan KH, Gomes S, Singarayar S, McGuire M, Lee G, Hunter R, Berriman T, Diab I, Kamdar R, Richmond L, Baker V, Goromonzi F, Sawhney V, Duncan E, Unsworth B, Mayet J, Abrams D, Dhinoja M, Sporton S, Earley M, Schilling RJ, Bowers RW, Mulholland V, Balasubramaniam RN, Paisey JR, Sopher SM, Chu GS, Chin SH, Winter J, Armstrong S, Masca N, Almeida TP, Brown PD, Sandilands AJ, Schlindwein FS, Ng GA. ABSTRACTS FOR ORAL PRESENTATION, SESSION 2, HRC 2013. Europace 2013. [DOI: 10.1093/europace/eut315] [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: 11/13/2022] Open
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Geerts H, Roberts P, Spiros A. A quantitative system pharmacology computer model for cognitive deficits in schizophrenia. CPT Pharmacometrics Syst Pharmacol 2013; 2:e36. [PMID: 23887686 PMCID: PMC3636495 DOI: 10.1038/psp.2013.12] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 02/08/2013] [Indexed: 01/29/2023] Open
Abstract
Although the positive symptoms of schizophrenia are reasonably well-controlled by current antipsychotics, cognitive impairment remains largely unaddressed. The Matrics initiative lays out a regulatory path forward and a number of targets have been tested in the clinic, so far without much success. To address this translational disconnect, we have developed a mechanism-based humanized computer model of a relevant key cortical brain network with schizophrenia pathology involved with the maintenance aspect of working memory (WM). The model is calibrated using published clinical experiments on N-back WM tests. We further simulate the opposite effect of γ-aminobutyric acid (GABA) modulators lorazepam and flumazenil and of a published augmentation trial of clozapine with risperidone, illustrating the introduction of new targets and the capacity of predicting the effects of polypharmacy. This humanized approach allows for early prospective and quantitative assessment of cognitive outcome in a central nervous system (CNS) research and development project, thereby hopefully increasing the success rate of clinical trials.CPT: Pharmacometrics & Systems Pharmacology (2013) 2, e36; doi:10.1038/psp.2013.12; advance online publication 3 April 2013.
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Affiliation(s)
- H Geerts
- In Silico Biosciences, Berwyn, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - P Roberts
- In Silico Biosciences, Berwyn, Pennsylvania, USA
- OHSUPortland, Oregon, USA
| | - A Spiros
- In Silico Biosciences, Berwyn, Pennsylvania, USA
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Fry WE, McGrath MT, Seaman A, Zitter TA, McLeod A, Danies G, Small IM, Myers K, Everts K, Gevens AJ, Gugino BK, Johnson SB, Judelson H, Ristaino J, Roberts P, Secor G, Seebold K, Snover-Clift K, Wyenandt A, Grünwald NJ, Smart CD. The 2009 Late Blight Pandemic in the Eastern United States - Causes and Results. Plant Dis 2013; 97:296-306. [PMID: 30722376 DOI: 10.1094/pdis-08-12-0791-fe] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The tomato late blight pandemic of 2009 made late blight into a household term in much of the eastern United States. Many home gardeners and many organic producers lost most if not all of their tomato crop, and their experiences were reported in the mainstream press. Some CSAs (Community Supported Agriculture) could not provide tomatoes to their members. In response, many questions emerged: How did it happen? What was unusual about this event compared to previous late blight epidemics? What is the current situation in 2012 and what can be done? It's easiest to answer these questions, and to understand the recent epidemics of late blight, if one knows a bit of the history of the disease and the biology of the causal agent, Phytophthora infestans.
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Affiliation(s)
- W E Fry
- Cornell University, Ithaca, NY
| | | | | | | | - A McLeod
- University of Stellenbosch, Stellenbosch, South Africa
| | | | | | - K Myers
- Cornell University, Ithaca, NY
| | - K Everts
- University of Maryland, Salisbury
| | | | - B K Gugino
- The Pennsylvania State University, University Park
| | - S B Johnson
- University of Maine Cooperative Extension, Presque Isle
| | | | - J Ristaino
- North Carolina State University, Raleigh
| | | | - G Secor
- North Dakota State University, Fargo
| | | | | | - A Wyenandt
- Rutgers Agricultural Research and Extension Center, Bridgeton, NJ
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Geerts H, Spiros A, Roberts P, Carr R. Has the time come for predictive computer modeling in CNS drug discovery and development? CPT Pharmacometrics Syst Pharmacol 2012; 1:e16. [PMID: 23835798 PMCID: PMC3600733 DOI: 10.1038/psp.2012.17] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
We discuss whether a new paradigm, quantitative systems pharmacology (QSP), based on computational neuroscience modeling combined with proper drug target engagement and pharmacology, human pathology, imaging studies, and calibration and validation using clinical studies in human subjects might improve the success rate of central nervous systems research and development (CNS R&D) projects. We suggest that an improved understanding of neuronal circuit interactions using a humanized computer-based integration of physiology and pharmacology knowledge can substantially de-risk new CNS projects.
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Affiliation(s)
- H Geerts
- 1] Department of Biomedical Engineering, In Silico Biosciences, Berwyn, Pennsylvania, USA [2] Department of Biomedical Engineering, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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