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Walsh TS, Aitken LM, McKenzie CA, Boyd J, Macdonald A, Giddings A, Hope D, Norrie J, Weir C, Parker RA, Lone NI, Emerson L, Kydonaki K, Creagh-Brown B, Morris S, McAuley DF, Dark P, Wise MP, Gordon AC, Perkins G, Reade M, Blackwood B, MacLullich A, Glen R, Page VJ. Alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B Trial): protocol for a multicentre phase 3 pragmatic clinical and cost-effectiveness randomised trial in the UK. BMJ Open 2023; 13:e078645. [PMID: 38072483 PMCID: PMC10729141 DOI: 10.1136/bmjopen-2023-078645] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Almost all patients receiving mechanical ventilation (MV) in intensive care units (ICUs) require analgesia and sedation. The most widely used sedative drug is propofol, but there is uncertainty whether alpha2-agonists are superior. The alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B) trial aims to determine whether clonidine or dexmedetomidine (or both) are clinically and cost-effective in MV ICU patients compared with usual care. METHODS AND ANALYSIS Adult ICU patients within 48 hours of starting MV, expected to require at least 24 hours further MV, are randomised in an open-label three arm trial to receive propofol (usual care) or clonidine or dexmedetomidine as primary sedative, plus analgesia according to local practice. Exclusions include patients with primary brain injury; postcardiac arrest; other neurological conditions; or bradycardia. Unless clinically contraindicated, sedation is titrated using weight-based dosing guidance to achieve a Richmond-Agitation-Sedation score of -2 or greater as early as considered safe by clinicians. The primary outcome is time to successful extubation. Secondary ICU outcomes include delirium and coma incidence/duration, sedation quality, predefined adverse events, mortality and ICU length of stay. Post-ICU outcomes include mortality, anxiety and depression, post-traumatic stress, cognitive function and health-related quality of life at 6-month follow-up. A process evaluation and health economic evaluation are embedded in the trial.The analytic framework uses a hierarchical approach to maximise efficiency and control type I error. Stage 1 tests whether each alpha2-agonist is superior to propofol. If either/both interventions are superior, stages 2 and 3 testing explores which alpha2-agonist is more effective. To detect a mean difference of 2 days in MV duration, we aim to recruit 1437 patients (479 per group) in 40-50 UK ICUs. ETHICS AND DISSEMINATION The Scotland A REC approved the trial (18/SS/0085). We use a surrogate decision-maker or deferred consent model consistent with UK law. Dissemination will be via publications, presentations and updated guidelines. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT03653832.
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Affiliation(s)
- Timothy Simon Walsh
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | - Julia Boyd
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Alix Macdonald
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Annabel Giddings
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | - John Norrie
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh No. 9, Bioquarter, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Nazir I Lone
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | - Benedict Creagh-Brown
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
- Intensive Care Unit, Royal Surrey County Hospital, Guildford, UK
| | - Stephen Morris
- Primary Care Unit, University of Cambridge, Cambridge, UK
| | | | - Paul Dark
- Intensive Care Unit, University of Manchester, Greater Manchester, UK
| | - Matt P Wise
- Department of Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Gavin Perkins
- Clinical Trials Unit, University of Warwick, Birmingham, UK
| | - Michael Reade
- University of Queensland, Brisbane, Queensland, Australia
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | | | - Valerie J Page
- Intensive Care, West Hertfordshire Hospitals NHS Trust, Watford, UK
- Faculty of Medicine, Imperial College London, London, UK
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Wong C, Dakin RS, Williamson J, Newton J, Steven M, Colville S, Stavrou M, Gregory JM, Elliott E, Mehta AR, Chataway J, Swingler RJ, Parker RA, Weir CJ, Stallard N, Parmar MKB, Macleod MR, Pal S, Chandran S. Motor Neuron Disease Systematic Multi-Arm Adaptive Randomised Trial (MND-SMART): a multi-arm, multi-stage, adaptive, platform, phase III randomised, double-blind, placebo-controlled trial of repurposed drugs in motor neuron disease. BMJ Open 2022; 12:e064173. [PMID: 35798516 PMCID: PMC9263927 DOI: 10.1136/bmjopen-2022-064173] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Motor neuron disease (MND) is a rapidly fatal neurodegenerative disease. Despite decades of research and clinical trials there remains no cure and only one globally approved drug, riluzole, which prolongs survival by 2-3 months. Recent improved mechanistic understanding of MND heralds a new translational era with many potential targets being identified that are ripe for clinical trials. Motor Neuron Disease Systematic Multi-Arm Adaptive Randomised Trial (MND-SMART) aims to evaluate the efficacy of drugs efficiently and definitively in a multi-arm, multi-stage, adaptive trial. The first two drugs selected for evaluation in MND-SMART are trazodone and memantine. METHODS AND ANALYSIS Initially, up to 531 participants (177/arm) will be randomised 1:1:1 to oral liquid trazodone, memantine and placebo. The coprimary outcome measures are the Amyotrophic Lateral Sclerosis Functional Rating Scale Revised (ALSFRS-R) and survival. Comparisons will be conducted in four stages. The decision to continue randomising to arms after each stage will be made by the Trial Steering Committee who receive recommendations from the Independent Data Monitoring Committee. The primary analysis of ALSFRS-R will be conducted when 150 participants/arm, excluding long survivors, have completed 18 months of treatment; if positive the survival effect will be inferentially analysed when 113 deaths have been observed in the placebo group. The trial design ensures that other promising drugs can be added for evaluation in planned trial adaptations. Using this novel trial design reduces time, cost and number of participants required to definitively (phase III) evaluate drugs and reduces exposure of participants to potentially ineffective treatments. ETHICS AND DISSEMINATION MND-SMART was approved by the West of Scotland Research Ethics Committee on 2 October 2019. (REC reference: 19/WS/0123) Results of the study will be submitted for publication in a peer-reviewed journal and a summary provided to participants. TRIAL REGISTRATION NUMBERS European Clinical Trials Registry (2019-000099-41); NCT04302870.
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Affiliation(s)
- Charis Wong
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Rachel S Dakin
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Jill Williamson
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Judith Newton
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Michelle Steven
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Shuna Colville
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Maria Stavrou
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Jenna M Gregory
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Elizabeth Elliott
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Arpan R Mehta
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Robert J Swingler
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- London North West University Healthcare NHS Trust, Northwick Park Hospital, London, UK
| | - Richard Anthony Parker
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mahesh K B Parmar
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Malcolm R Macleod
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Suvankar Pal
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Siddharthan Chandran
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
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Walsh TS, Pauley E, Donaghy E, Thompson J, Barclay L, Parker RA, Weir C, Marple J. Does a screening checklist for complex health and social care needs have potential clinical usefulness for predicting unplanned hospital readmissions in intensive care survivors: development and prospective cohort study. BMJ Open 2022; 12:e056524. [PMID: 35321894 PMCID: PMC8943772 DOI: 10.1136/bmjopen-2021-056524] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Intensive care (ICU) survivors are at high risk of long-term physical and psychosocial problems. Unplanned hospital readmission rates are high, but the best way to triage patients for interventions is uncertain. We aimed to develop and evaluate a screening checklist to help predict subsequent readmissions or deaths. DESIGN A checklist for complex health and social care needs (CHSCNs) was developed based on previous research, comprising six items: multimorbidity; polypharmacy; frequent previous hospitalisations; mental health issues; fragile social circumstances and impaired activities of daily living. Patients were considered to have CHSCNs if two or more were present. We prospectively screened all ICU discharges for CHSCNs for 12 months. SETTING ICU, Royal Infirmary, Edinburgh, UK. PARTICIPANTS ICU survivors over a 12-month period (1 June 2018 and 31 May 2019). INTERVENTIONS None. OUTCOME MEASURE Readmission or death in the community within 3 months postindex hospital discharge. RESULTS Of 1174 ICU survivors, 937 were discharged alive from the hospital. Of these 253 (27%) were classified as having CHSCNs. In total 28% (266/937) patients were readmitted (N=238) or died (N=28) within 3 months. Among CHSCNs patients 45% (n=115) patients were readmitted (N=105) or died (N=10). Patients without CHSCNs had a 22% readmission (N=133) or death (N=18) rate. The checklist had: sensitivity 43% (95% CI 37% to 49%), specificity 79% (95% CI 76% to 82%), positive predictive value 45% (95% CI 41% to 51%), and negative predictive value 78% (95% CI 76% to 80%). Relative risk of readmission/death for patients with CHSCNs was 2.06 (95% CI 1.69 to 2.50), indicating a pretest to post-test probability change of 28%-45%. The checklist demonstrated high inter-rater reliability (percentage agreement ≥87% for all domains; overall kappa, 0.84). CONCLUSIONS Early evaluation of a screening checklist for CHSCNs at ICU discharge suggests potential clinical usefulness, but this requires further evaluation as part of a care pathway.
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Affiliation(s)
- Timothy Simon Walsh
- Critical Care Medicine; Usher Institute of Population Health Sciences, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Ellen Pauley
- Department of Anaesthesia, Critical Care & Pain Medicine, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Eddie Donaghy
- Department of Anaesthesia, Critical Care & Pain Medicine, NHS Lothian, Edinburgh, UK
| | - Joanne Thompson
- Department of Anaesthesia, Critical Care & Pain Medicine, NHS Lothian, Edinburgh, UK
| | - Lucy Barclay
- Department of Anaesthesia, Critical Care & Pain Medicine, NHS Lothian, Edinburgh, UK
| | | | - Christopher Weir
- Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - James Marple
- Department of Anaesthesia, Critical Care & Pain Medicine, NHS Lothian, Edinburgh, UK
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Warner P, Whitaker LHR, Parker RA, Weir CJ, Douglas A, Hansen CH, Madhra M, Hillier SG, Saunders PTK, Iredale JP, Semple S, Slayden OD, Walker BR, Critchley HOD. Low dose dexamethasone as treatment for women with heavy menstrual bleeding: A response-adaptive randomised placebo-controlled dose-finding parallel group trial (DexFEM). EBioMedicine 2021; 69:103434. [PMID: 34218053 PMCID: PMC8261537 DOI: 10.1016/j.ebiom.2021.103434] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/21/2021] [Accepted: 05/25/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The symptom of heavy menstrual bleeding (HMB) diminishes quality-of-life for many mid-age women and imposes substantial societal burden. We investigated our hypothesis that HMB reflects impaired endometrial vasoconstriction due to endometrial glucocorticoid deficiency. Does reversing this deficiency, by short-term luteal-phase treatment with exogenous glucocorticoid (dexamethasone), ameliorate HMB? METHODS In our Bayesian response-adaptive parallel-group placebo-controlled randomised trial, five pre-planned interim analyses used primary outcome data to adjust randomisation probabilities to favour doses providing most dose-response information. Participants with HMB, recruited from Lothian (Scotland) NHS clinics and via community invitations/advertisements, were aged over 18 years; reported regular 21-42 day menstrual cycles; and had measured menstrual blood loss (MBL) averaging ≥ 50 mL over two screening periods. Identically encapsulated placebo, or one of six Dexamethasone doses (0·2 mg, 0·4 mg, 0·5 mg, 0·6 mg, 0·75 mg, 0·9 mg), were taken orally twice-daily over five days in the mid-luteal phase of three menstrual cycles. Participants, investigators, and those measuring outcomes were masked to group assignment. Primary outcome, change in average MBL from screening to 'treatment', was analysed by allocated treatment, for all with data. TRIAL REGISTRATION ClinicalTrials.gov NCT01769820; EudractCT 2012-003,405-98 FINDINGS: Recruitment lasted 29/01/2014 to 25/09/2017; 176 were screened, 107 randomised and 97 provided primary outcome data (n = 24,5,9,21,8,14,16 in the seven arms, placebo to 1·8 mg total daily active dose). In Bayesian normal dynamic linear modelling, 1·8 mg dexamethasone daily showed a 25 mL greater reduction in MBL from screening, than placebo (95% credible interval 1 to 49 mL), and probability 0·98 of benefit over placebo. Adverse events were reported by 75% (58/77) receiving dexamethasone, 58% (15/26) taking placebo. Three serious adverse events occurred, two during screening, one in a placebo participant. No woman withdrew due to adverse effects. INTERPRETATION Our adaptive trial in HMB showed that dexamethasone 1·8 mg daily reduced menstrual blood loss. The role of dexamethasone in HMB management deserves further investigation. FUNDING UK MRC DCS/DPFS grant MR/J003611/1.
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Affiliation(s)
- Pamela Warner
- Usher Institute, University of Edinburgh, Edinburgh, UK.
| | | | - Richard Anthony Parker
- Usher Institute, University of Edinburgh, Edinburgh, UK; Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Christopher John Weir
- Usher Institute, University of Edinburgh, Edinburgh, UK; Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Anne Douglas
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Christian Holm Hansen
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Mayank Madhra
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | | | | | - John Peter Iredale
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol foundation Trust, Bristol, UK
| | - Scott Semple
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Ov Daniel Slayden
- Division of Reproductive and Developmental Sciences, Oregon National Primate Research Center, Oregon, USA
| | - Brian Robert Walker
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, UK; Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
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Holloway A, Guthrie V, Waller G, Smith J, Boyd J, Mercado S, Smith P, Stenhouse R, Sheikh A, Parker RA, Stoddart A, Conaglen P, Coulton S, Stadler G, Hunt K, Bray J, Ferguson J, Sondhi A, Lynch K, Rees J, Newbury-Birch D. A two-arm parallel-group individually randomised prison pilot study of a male remand alcohol intervention for self-efficacy enhancement: the APPRAISE study protocol. BMJ Open 2021; 11:e040636. [PMID: 33811049 PMCID: PMC8023744 DOI: 10.1136/bmjopen-2020-040636] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The prevalence of at-risk drinking is far higher among those in contact with the criminal justice system (73%) than the general population (35%). However, there is little evidence on the effectiveness of alcohol brief interventions (ABIs) in reducing risky drinking among those in the criminal justice system, including the prison system and, in particular, those on remand. Building on earlier work, A two-arm parallel group individually randomised Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement (APPRAISE) is a pilot study designed to assess the feasibility and acceptability of an ABI, delivered to male prisoners on remand. The findings of APPRAISE should provide the information required to design a future definitive randomised controlled trial (RCT). METHODS AND ANALYSIS APPRAISE will use mixed methods, with two linked phases, across two prisons in the UK, recruiting 180 adult men on remand: 90 from Scotland and 90 from England. Phase I will involve a two-arm, parallel-group, individually randomised pilot study. The pilot evaluation will provide data on the likely impact of A two-arm parallel group individually randomised Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement (APPRAISE), which will be used to inform a future definitive multicentre RCT. Phase II will be a process evaluation assessing how the ABI has been implemented to explore the change mechanisms underpinning the ABI (figure 1) and to assess the context within which the ABI is delivered. ETHICS AND DISSEMINATION The APPRAISE protocol has been approved by the East of Scotland Research Ethics Committee (19/ES/0068), National Offender Management System (2019-240), Health Board Research and Development (2019/0268), Scottish Prison Service research and ethics committee, and by the University of Edinburgh's internal ethics department. The findings will be disseminated via peer-reviewed journal publications, presentations at local, national and international conferences, infographics and shared with relevant stakeholders through meetings and events. TRIAL REGISTRATION NUMBER ISRCTN27417180.
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Affiliation(s)
- Aisha Holloway
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK
| | - Victoria Guthrie
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK
| | - Gillian Waller
- School of Social Sciences, Humanities & Law, Teesside University, Middlesbrough, UK
| | - Jamie Smith
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK
- Institute for Gender Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Joanne Boyd
- School of Social Sciences, Humanities & Law, Teesside University, Middlesbrough, UK
- Centre for Change, County Durham Drug and Alcohol Recovery Service, Durham, UK
| | - Sharon Mercado
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK
| | - Pam Smith
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK
| | - Rosie Stenhouse
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Division of Community Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Andrew Stoddart
- Edinburgh Health Services Research Unit, The University Of Edinburgh, Edinburgh, UK
| | | | - Simon Coulton
- Centre for Health Service Studies, University of Kent, Canterbury, UK
| | - Gertraud Stadler
- Institute for Gender Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
- University of Aberdeen, Aberdeen, UK
| | - Kate Hunt
- Institute of Social Marketing, University of Stirling, Stirling, UK
| | - Jeremy Bray
- Department of Economics, University of North Carolina at Greensboro, Greensborough, UK
| | - Jennifer Ferguson
- School of Social Sciences, Humanities & Law, Teesside University, Middlesbrough, UK
| | | | - Kieran Lynch
- Criminal Justice, Alcohol, Drugs and Tobacco Division, Public Health England, London, UK
| | - Jessica Rees
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
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Solanky BS, John NA, DeAngelis F, Stutters J, Prados F, Schneider T, Parker RA, Weir CJ, Monteverdi A, Plantone D, Doshi A, MacManus D, Marshall I, Barkhof F, Gandini Wheeler-Kingshott CAM, Chataway J. NAA is a Marker of Disability in Secondary-Progressive MS: A Proton MR Spectroscopic Imaging Study. AJNR Am J Neuroradiol 2020; 41:2209-2218. [PMID: 33154071 DOI: 10.3174/ajnr.a6809] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 06/03/2020] [Accepted: 07/24/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE The secondary progressive phase of multiple sclerosis is characterised by disability progression due to processes that lead to neurodegeneration. Surrogate markers such as those derived from MRI are beneficial in understanding the pathophysiology that drives disease progression and its relationship to clinical disability. We undertook a 1H-MRS imaging study in a large secondary progressive MS (SPMS) cohort, to examine whether metabolic markers of brain injury are associated with measures of disability, both physical and cognitive. MATERIALS AND METHODS A cross-sectional analysis of individuals with secondary-progressive MS was performed in 119 participants. They underwent 1H-MR spectroscopy to obtain estimated concentrations and ratios to total Cr for total NAA, mIns, Glx, and total Cho in normal-appearing WM and GM. Clinical outcome measures chosen were the following: Paced Auditory Serial Addition Test, Symbol Digit Modalities Test, Nine-Hole Peg Test, Timed 25-foot Walk Test, and the Expanded Disability Status Scale. The relationship between these neurometabolites and clinical disability measures was initially examined using Spearman rank correlations. Significant associations were then further analyzed in multiple regression models adjusting for age, sex, disease duration, T2 lesion load, normalized brain volume, and occurrence of relapses in 2 years preceding study entry. RESULTS Significant associations, which were then confirmed by multiple linear regression, were found in normal-appearing WM for total NAA (tNAA)/total Cr (tCr) and the Nine-Hole Peg Test (ρ = 0.23; 95% CI, 0.06-0.40); tNAA and tNAA/tCr and the Paced Auditory Serial Addition Test (ρ = 0.21; 95% CI, 0.03-0.38) (ρ = 0.19; 95% CI, 0.01-0.36); mIns/tCr and the Paced Auditory Serial Addition Test, (ρ = -0.23; 95% CI, -0.39 to -0.05); and in GM for tCho and the Paced Auditory Serial Addition Test (ρ = -0.24; 95% CI, -0.40 to -0.06). No other GM or normal-appearing WM relationships were found with any metabolite, with associations found during initial correlation testing losing significance after multiple linear regression analysis. CONCLUSIONS This study suggests that metabolic markers of neuroaxonal integrity and astrogliosis in normal-appearing WM and membrane turnover in GM may act as markers of disability in secondary-progressive MS.
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Affiliation(s)
- B S Solanky
- From the Department of Neuroinflammation (B.S.S., N.A.J., F.D., J.S., F.P., D.P., A.D., D.M., C.A.M.G.W.-K., J.C.), Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology
| | - N A John
- From the Department of Neuroinflammation (B.S.S., N.A.J., F.D., J.S., F.P., D.P., A.D., D.M., C.A.M.G.W.-K., J.C.), Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology
| | - F DeAngelis
- From the Department of Neuroinflammation (B.S.S., N.A.J., F.D., J.S., F.P., D.P., A.D., D.M., C.A.M.G.W.-K., J.C.), Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology
| | - J Stutters
- From the Department of Neuroinflammation (B.S.S., N.A.J., F.D., J.S., F.P., D.P., A.D., D.M., C.A.M.G.W.-K., J.C.), Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology
| | - F Prados
- From the Department of Neuroinflammation (B.S.S., N.A.J., F.D., J.S., F.P., D.P., A.D., D.M., C.A.M.G.W.-K., J.C.), Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology
- Centre for Medical Image Computing (F.P., F.B.), Department of Medical Physics and Biomedical Engineering, University College London, London, UK
- Universitat Oberta de Catalunya (F.P.), Barcelona, Spain
| | | | - R A Parker
- Edinburgh Clinical Trials Unit (R.A.P., C.J.W.), Usher Institute
| | - C J Weir
- Edinburgh Clinical Trials Unit (R.A.P., C.J.W.), Usher Institute
| | - A Monteverdi
- Department of Brain and Behavioural Sciences (A.M., C.A.M.G.W.-K.), University of Pavia, Pavia, Italy
| | - D Plantone
- From the Department of Neuroinflammation (B.S.S., N.A.J., F.D., J.S., F.P., D.P., A.D., D.M., C.A.M.G.W.-K., J.C.), Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology
| | - A Doshi
- From the Department of Neuroinflammation (B.S.S., N.A.J., F.D., J.S., F.P., D.P., A.D., D.M., C.A.M.G.W.-K., J.C.), Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology
| | - D MacManus
- From the Department of Neuroinflammation (B.S.S., N.A.J., F.D., J.S., F.P., D.P., A.D., D.M., C.A.M.G.W.-K., J.C.), Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology
| | - I Marshall
- Centre for Clinical Brain Sciences (I.M.), University of Edinburgh, Edinburgh, UK
| | - F Barkhof
- Centre for Medical Image Computing (F.P., F.B.), Department of Medical Physics and Biomedical Engineering, University College London, London, UK
- National Institute for Health Research (F.B.), University College London Hospitals Biomedical Research Centre, London, UK
- Department of Radiology and Nuclear Medicine (F.B., J.C.), MS Center Amsterdam, Amsterdam, the Netherlands
| | - C A M Gandini Wheeler-Kingshott
- From the Department of Neuroinflammation (B.S.S., N.A.J., F.D., J.S., F.P., D.P., A.D., D.M., C.A.M.G.W.-K., J.C.), Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology
- Brain MRI 3T Research Center (C.A.M.G.W.-K.), Scientific Institute for Research, Hospitalization and Healthcare Mondino National Neurological Institute Foundation, Pavia, Italy
- Department of Brain and Behavioural Sciences (A.M., C.A.M.G.W.-K.), University of Pavia, Pavia, Italy
| | - J Chataway
- From the Department of Neuroinflammation (B.S.S., N.A.J., F.D., J.S., F.P., D.P., A.D., D.M., C.A.M.G.W.-K., J.C.), Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology
- Department of Radiology and Nuclear Medicine (F.B., J.C.), MS Center Amsterdam, Amsterdam, the Netherlands
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7
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Croxford AK, Parker RA, Burford JH, Lloyd D, Boswell JC, Hughes TK, Phillips TJ. Chondromalacia of the cranial medial femoral condyle; its occurrence and association with clinical outcome in a population of adult horses with stifle lameness. Equine Vet J 2019; 52:379-383. [PMID: 31710379 DOI: 10.1111/evj.13205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 10/25/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chondromalacia of the cranial medial femoral condyle (CMFC) is a potential cause of stifle lameness in adult horses. However, there is scant published evidence of either its occurrence or its clinical significance. OBJECTIVES To document the occurrence of CMFC seen during diagnostic arthroscopy in adult horses with stifle lameness and to investigate its prognostic significance. STUDY DESIGN Retrospective cohort study. METHODS The records were reviewed of all horses with unilateral or bilateral lameness localised to the stifle that underwent diagnostic arthroscopy of the cranial medial femorotibial joint at a UK equine hospital. The surgical findings were noted from each. Case outcomes were determined by unstructured telephone discussions with owners. A satisfactory outcome was defined as a horse that was in ridden work without ongoing anti-inflammatory medication. Multivariable logistic regression was used to create a model with an outcome time point at 12-month post-operatively. RESULTS One hundred and four horses were included in the study. CMFC was found in 79. In 25 CMFC was the only finding, 54 horses had CMFC plus other pathology and 25 had other pathology, but no CMFC. At 12 months, horses with CMFC were 9.9 (95% CI 2.2-45.0, P<0.01) times more likely to have an unsatisfactory outcome than horses without CMFC. MAIN LIMITATIONS The study relied on retrospective analysis of clinical notes and archived arthroscopy videos. Assessment of outcome was determined by unstructured telephone interview and therefore there is potential for reporting errors to exist. CONCLUSIONS CMFC is a common arthroscopic finding in horses with stifle lameness and is significantly associated with an increased likelihood of the horse not being in ridden work at long-term follow-up.
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Affiliation(s)
| | - R A Parker
- Liphook Equine Hospital, Liphook, Hampshire, UK
| | - J H Burford
- School of Veterinary Medicine and Surgery, University of Nottingham, Sutton Bonington, Leicestershire, UK
| | - D Lloyd
- Liphook Equine Hospital, Liphook, Hampshire, UK
| | - J C Boswell
- Liphook Equine Hospital, Liphook, Hampshire, UK
| | - T K Hughes
- Liphook Equine Hospital, Liphook, Hampshire, UK
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8
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Abstract
Background The physical demands of firefighting require both cardiovascular and muscular fitness, which both decline with age. While much has been published on age-related changes among male firefighters (FFs), data on female FFs are lacking. Aims To describe cardiorespiratory fitness (CRF) and muscular fitness in a sample of female career FFs ranging in age from 25 to 60 years and determine whether ageing affects their achievement of the current recommended professional CRF standards of 12 metabolic equivalents (METs). Methods Data were collected on female FFs over an 11-year period. A cross-sectional analysis using one-way analysis of variance with Bonferroni post hoc comparisons was used to compare age groups. Results There were 96 study participants. Maximum METs was significantly higher (P < 0.01) in the 25- to 34-year age group (14.6 ± 2.1) compared with the 35-44 age group (12.9 ± 2.0 METs) and the 45-54 age group (12.2 ± 1.8 METs, P < 0.001). While the mean values of all measured age groups met or exceeded the 12-MET profession standard, as many as one-third of FFs <45 years of age and 43% of FFs >45 years of age fell below the benchmark of 12 METs. Muscular fitness as measured by maximum number of push-ups, sit-ups and back endurance was not significantly different between age groups. Conclusions Fire departments should recognize and take steps to ensure all female FFs maintain CRF and muscular fitness throughout their careers.
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Affiliation(s)
- L K Kirlin
- School of Exercise and Nutritional Sciences, San Diego State University, San Diego, CA 92182, USA.,San Diego Firefighters' Regional Fire Wellness Program, San Diego Sports Medicine and Family Health Center, San Diego, CA 92120, USA
| | - J F Nichols
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA 92093, USA
| | - K Rusk
- San Diego Firefighters' Regional Fire Wellness Program, San Diego Sports Medicine and Family Health Center, San Diego, CA 92120, USA
| | - R A Parker
- San Diego Firefighters' Regional Fire Wellness Program, San Diego Sports Medicine and Family Health Center, San Diego, CA 92120, USA
| | - M J Rauh
- School of Exercise and Nutritional Sciences, San Diego State University, San Diego, CA 92182, USA.,Doctor of Physical Therapy Program, San Diego State University, San Diego, CA 92182, USA
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9
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O'Laughlin KN, Kasozi J, Rabideau DJ, Parker RA, Mulogo E, Faustin ZM, Greenwald KE, Doraiswamy S, Walensky RP, Bassett IV. The cascade of HIV care among refugees and nationals in Nakivale Refugee Settlement in Uganda. HIV Med 2017; 18:513-518. [PMID: 28070923 DOI: 10.1111/hiv.12476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 10/01/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Refugees living in Uganda come from HIV-endemic countries, and many remain in refugee settlements for over a decade. Our objective was to evaluate the HIV care cascade in Nakivale Refugee Settlement and to assess correlates of linkage to care. METHODS We prospectively enrolled individuals accessing clinic-based HIV testing in Nakivale Refugee Settlement from March 2013 to July 2014. Newly HIV-diagnosed clients were followed for 3 months post-diagnosis. Clients underwent a baseline survey. The following outcomes were obtained from HIV clinic registers in Nakivale: clinic attendance ('linkage to HIV care'), CD4 testing, antiretroviral therapy (ART) eligibility, and ART initiation within 90 days of testing. Descriptive data were reported as frequency with 95% confidence interval (CI) or median with interquartile range (IQR). The impact of baseline variables on linkage to care was assessed with logistic regression models. RESULTS Of 6850 adult clients tested for HIV, 276 (4%; CI: 3-5%) were diagnosed with HIV infection, 148 (54%; CI: 47-60%) of those were linked to HIV care, 54 (20%; CI: 15-25%) had a CD4 test, 22 (8%; CI: 5-12%) were eligible for ART, and 17 (6%; CI: 3-10%) initiated ART. The proportions of refugees and nationals at each step of the cascade were similar. We identified no significant predictors of linkage to care. CONCLUSIONS Less than a quarter of newly HIV-diagnosed clients completed ART assessment, considerably lower than in other reports from sub-Saharan Africa. Understanding which factors hinder linkage to and engagement in care in the settlement will be important to inform interventions specific for this environment.
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Affiliation(s)
- K N O'Laughlin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard Humanitarian Initiative, Cambridge, MA, USA
| | - J Kasozi
- Representation in Uganda, United Nations High Commissioner for Refugees, Kampala, Uganda
| | - D J Rabideau
- Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA
| | - R A Parker
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - E Mulogo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Z M Faustin
- Kasese Campus, Bugema University, Kampala, Uganda
| | | | - S Doraiswamy
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - R P Walensky
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - I V Bassett
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
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10
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Kanaan M, Mdege ND, Keding A, Parker RA, Mills N, Shah A, Strachan F, Keerie C, Weir CJ, Forbes A, Hemming K, Lawton SA, Healey E, Lewis M, Nicholls E, Jinks C, Tan V, Finney A, Mallen CD, Lenguerrand E, MacLennan G, Norrie J, Bhattacharya S, Draycott T, Hooper R, Teerenstra S, de Hoop E, Eldridge S, Girling A, Taljaard M, Di Tanna GL, Gasparrini A, Casula A, Caskey F, Lenguerrand E, Methven S, MacNeill S, May M, Selby N, Danon L, Christensen H, Finn A, May M, Takanashi F, Keding A, Crouch S, Kanaan M, Kristunas CA, Smith KL, Gray LJ, Matthews JN, Salman RAS, Parker RA, Maxwell A, Dennis M, Rudd A, Weir CJ, Thompson JA, Fielding KL, Davey C, Aiken AM, Hargreaves JR, Hayes RJ, Lyons VH, Li L, Hughes J, Rowhani-Rahbar A, Hemming K, Taljaard M, Forbes A. Proceedings of the First International Conference on Stepped Wedge Trial Design. Trials 2016; 17 Suppl 1:311. [PMID: 27454562 PMCID: PMC4959349 DOI: 10.1186/s13063-016-1436-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
I1 Introduction Mona Kanaan, Noreen Dadirai Mdege, Ada Keding O1 The HiSTORIC trial: a hybrid before-and-after and stepped wedge design RA Parker, N Mills, A Shah, F Strachan, C Keerie, CJ Weir O2 Stepped wedge trials with non-uniform correlation structure Andrew Forbes, Karla Hemming O3 Challenges and solutions for the operationalisation of the ENHANCE study: a pilot stepped wedge trial within a general practice setting Sarah A Lawton, Emma Healey, Martyn Lewis, Elaine Nicholls, Clare Jinks, Valerie Tan, Andrew Finney, Christian D Mallen, on behalf of the ENHANCE Study Team O4 Early lessons from the implementation of a stepped wedge trial design investigating the effectiveness of a training intervention in busy health care settings: the Thistle study Erik Lenguerrand, Graeme MacLennan, John Norrie, Siladitya Bhattacharya, Tim Draycott, on behalf of the Thistle group O5 Sample size calculation for longitudinal cluster randomised trials: a unified framework for closed cohort and repeated cross-section designs Richard Hooper, Steven Teerenstra, Esther de Hoop, Sandra Eldridge O6 Restricted randomisation schemes for stepped-wedge studies with a cluster-level covariate Alan Girling, Monica Taljaard O7 A flexible modelling of the time trend for the analysis of stepped wedge trials: results of a simulation study Gian Luca Di Tanna, Antonio Gasparrini P1 Tackling acute kidney injury – a UK stepped wedge clinical trial of hospital-level quality improvement interventions Anna Casula, Fergus Caskey, Erik Lenguerrand, Shona Methven, Stephanie MacNeill, Margaret May, Nicholas Selby P2 Sample size considerations for quantifying secondary bacterial transmission in a stepped wedge trial of influenza vaccine Leon Danon, Hannah Christensen, Adam Finn, Margaret May P3 Sample size calculation for time-to-event data in stepped wedge cluster randomised trials Fumihito Takanashi, Ada Keding, Simon Crouch, Mona Kanaan P4 Sample size calculations for stepped-wedge cluster randomised trials with unequal cluster sizes Caroline A. Kristunas, Karen L. Smith, Laura J. Gray P5 The design of stepped wedge trials with unequal cluster sizes John N.S. Matthews P6 Promoting Recruitment using Information Management Efficiently (PRIME): a stepped wedge SWAT (study-within-a-trial) R Al-Shahi Salman, RA Parker, A Maxwell, M Dennis, A Rudd, CJ Weir P7 Implications of misspecified mixed effect models in stepped wedge trial analysis: how wrong can it be? Jennifer A Thompson, Katherine L Fielding, Calum Davey, Alexander M Aiken, James R Hargreaves, Richard J Hayes S1 Stepped Wedge Designs with Multiple Interventions Vivian H Lyons, Lingyu Li, James Hughes, Ali Rowhani-Rahbar S2 Analysis of the cross-sectional stepped wedge cluster randomised trial Karla Hemming, Monica Taljaard, Andrew Forbes
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11
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Iype S, David S, Hilliard S, Shaw A, Jamieson NV, Praseedom RK, Butler AJ, Huguet EL, Parker RA, Bradley JA, Watson CJE. When one becomes more: minimum renal artery length in laparoscopic live donor nephrectomy. Clin Transplant 2015; 29:588-93. [PMID: 25965009 DOI: 10.1111/ctr.12560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Laparoscopic donor nephrectomy may convert short main arteries into multiple arteries, increasing the technical challenge of implantation. We evaluated our experience to identify factors predictive of multiple arteries after laparoscopic nephrectomy. METHODS All laparoscopic nephrectomies from the start of our program in November 2002 until June 2013 were studied, and preoperative imaging reviewed for donor artery length and multiplicity together with operative findings. RESULTS A total of 287 consecutive laparoscopic live donor nephrectomies (64 right and 223 left nephrectomies) were studied. Renal artery length was measured from preoperative donor magnetic resonance or computed tomography angiogram and nephrectomy performed using a laparoscopic stapling device. Nine left kidneys with a single artery (6, 7, 9, 10, 11, 12, 13, 14, and 16 mm in length) and five right kidneys with a single artery (5, 13, 15, 20, and 26 mm) on imaging resulted in multiple renal arteries at implantation. Complex renal vein anatomy was associated with multiple arteries following retrieval. CONCLUSION A main renal artery length of more than 16 mm on the left and 26 mm on the right is unlikely to result in multiple arteries to implant. The possibility of multiple arteries should be borne in mind when the donor renal artery is short.
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Affiliation(s)
- S Iype
- University of Cambridge, Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,Cambridge NIHR Comprehensive Biomedical Research Centre, Cambridge, UK
| | - S David
- University of Cambridge, Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | - S Hilliard
- University of Cambridge, Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | - A Shaw
- University of Cambridge, Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | - N V Jamieson
- University of Cambridge, Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,Cambridge NIHR Comprehensive Biomedical Research Centre, Cambridge, UK
| | - R K Praseedom
- University of Cambridge, Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,Cambridge NIHR Comprehensive Biomedical Research Centre, Cambridge, UK
| | - A J Butler
- University of Cambridge, Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,Cambridge NIHR Comprehensive Biomedical Research Centre, Cambridge, UK
| | - E L Huguet
- University of Cambridge, Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,Cambridge NIHR Comprehensive Biomedical Research Centre, Cambridge, UK
| | - R A Parker
- Health Services Research Unit, University of Edinburgh, Edinburgh, UK
| | - J A Bradley
- University of Cambridge, Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,Cambridge NIHR Comprehensive Biomedical Research Centre, Cambridge, UK
| | - C J E Watson
- University of Cambridge, Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,Cambridge NIHR Comprehensive Biomedical Research Centre, Cambridge, UK
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12
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Reddy UD, Pillai R, Parker RA, Weston J, Burgess NA, Ho ETS, Mills RD, Rochester MA. Prediction of complications after partial nephrectomy by RENAL nephrometry score. Ann R Coll Surg Engl 2014; 96:475-9. [PMID: 25198982 DOI: 10.1308/003588414x13946184903522] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Discussing and planning the appropriate management for suspicious renal masses can be challenging. With the development of nephrometry scoring methods, we aimed to evaluate the ability of the RENAL nephrometry score to predict both the incidence of postoperative complications and the change in renal function after a partial nephrectomy. METHODS This was a retrospective study including 128 consecutive patients who underwent a partial nephrectomy (open and laparoscopic) for renal lesions in a tertiary UK referral centre. Univariate and multivariate ordinal regression models were used to identify associations between Clavien-Dindo classification and explanatory variables. The Kendall rank correlation coefficient was used to examine an association between RENAL nephrometry score and a drop in estimated glomerular filtration rate (eGFR) following surgery. RESULTS An increase in the RENAL nephrometry score of one point resulted in greater odds of being in a higher Clavien-Dindo classification after controlling for RENAL suffix and type of surgical procedure (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.04-1.64, p=0.043). Furthermore, a patient with the RENAL suffix 'p' (ie posterior location of tumour) had increased odds of developing more serious complications (OR: 2.60, 95% CI: 1.07-6.30, p=0.042). A correlation was shown between RENAL nephrometry score and postoperative drop in eGFR (Kendall's tau coefficient -0.24, p=0.004). CONCLUSIONS To our knowledge, this is the first study that has shown the predictive ability of the RENAL nephrometry scoring system in a UK cohort both in terms of postoperative complications and change in renal function.
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Affiliation(s)
- U D Reddy
- Norfolk and Norwich University Hospitals NHS Foundation Trust, UK
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13
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Panagiotopoulou IG, Fitzrol D, Parker RA, Kuzhively J, Luscombe N, Wells AD, Menon M, Bajwa FM, Watson MA. The yield of colorectal cancer among fast track patients with normocytic and microcytic anaemia. Ann R Coll Surg Engl 2014; 96:289-93. [PMID: 24780021 DOI: 10.1308/003588414x13814021680076] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION We receive fast track referrals on the basis of iron deficiency anaemia (IDA) for patients with normocytic anaemia or for patients with no iron studies. This study examined the yield of colorectal cancer (CRC) among fast track patients to ascertain whether awaiting confirmation of IDA is necessary prior to performing bowel investigations. METHODS A review was undertaken of 321 and 930 consecutive fast track referrals from Centre A and Centre B respectively. Contingency tables were analysed using Fisher's exact test. Logistic regression analyses were performed to investigate significant predictors of CRC. RESULTS Overall, 229 patients were included from Centre A and 689 from Centre B. The odds ratio for microcytic anaemia versus normocytic anaemia in the outcome of CRC was 1.3 (95% confidence interval [CI]: 0.5-3.9) for Centre A and 1.6 (95% CI: 0.8-3.3) for Centre B. In a logistic regression analysis (Centre B only), no significant difference in CRC rates was seen between microcytic and normocytic anaemia (adjusted odds ratio: 1.9, 95% CI: 0.9-3.9). There was no statistically significant difference in the yield of CRC between microcytic and normocytic anaemia (p=0.515, Fisher's exact test) in patients with anaemia only and no colorectal symptoms. Finally, CRC cases were seen in both microcytic and normocytic groups with or without low ferritin. CONCLUSIONS There is no significant difference in the yield of CRC between fast track patients with microcytic and normocytic anaemia. This study provides insufficient evidence to support awaiting confirmation of IDA in fast track patients with normocytic anaemia prior to requesting bowel investigations.
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14
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Abstract
OBJECTIVE To compare the length of hospitalisation for infants with bronchiolitis across the Eastern region and to assess the impact of the varying admission rates in each hospital. DESIGN Data collection through the Hospital Episode Statistics (HES) using the ICD clinical coding for bronchiolitis across all hospitals in east of England for three winter seasons (October to March for the years 2009/10, 2010/11 and 2011/12). MAIN OUTCOME MEASURE Length of hospital stay, corrected to adjust for local population. RESULTS Seventeen hospitals across the east of England were included in this study. Overall admission rate (as a percentage of the population) for the region was 3.3% and consistent with national data, but rates within individual hospitals varied between 1.5% and 5.7% over the 3-year period. Bed days per 1000 population ('standardised bed days') per year varied almost fourfold, from 34.5 to 122.3 in different hospitals. Corrected length of stay showed high discordance when compared to average length of stay. CONCLUSIONS The average length of stay is substantially affected by admission rates, with hospitals who admit a greater proportion of infants appearing to have a shorter uncorrected length of stay. We propose that a single corrected measure for length of stay should be used when assessing the efficiency of care because it is unaffected by variations in local admission rates and is adjusted for local population size.
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Affiliation(s)
- A Shahnaz
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, , Cambridge, UK
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15
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Ajose FOA, Parker RA, Merrall ELC, Adewuya AO, Zachariah MP. Quantification and comparison of psychiatric distress in African patients with albinism and vitiligo: a 5-year prospective study. J Eur Acad Dermatol Venereol 2013; 28:925-32. [PMID: 23875952 DOI: 10.1111/jdv.12216] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 05/05/2013] [Accepted: 06/21/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND Vitiligo and albinism are two disorders of pigmentation that make the affected African highly visible and strikingly different from their peers. Both pose considerable management challenges, attract significant stigma and profound impairment of quality of life. OBJECTIVE AND METHODS To determine and compare psychiatric distress in vitiligo and albinism using the Hospital Anxiety and Depression Scale (HADS). Participants were 87 albinos and 102 vitiligo adult patients seen at an urban tertiary hospital in Nigeria between 2004 and 2009. RESULTS Prevalence of psycho morbidity was 59% (60/102) in vitiligo compared with 26% (23/87) in the albinos. The mean anxiety score was estimated to be 2.55 points lower for albino patients (95% CI: 1.47 to 3.64), and the mean depression score 2.76 points lower (95% CI: 1.84 to 3.68), after adjustment for age, sex and marital status. However, significant differences were not observed when comparing the vitiligo patients with the subset of albino patients with skin cancer. Older patients had significantly higher anxiety and depression scores. Females had significantly higher anxiety scores (but not depression scores) compared to males. Genital involvement in vitiligo was significantly associated with anxiety but not depression. CONCLUSIONS We found that the African with vitiligo suffers significantly higher psychiatric distress than the African albino on average. Clinical evaluation of these patients would be incomplete without assessment of their psycho morbidity. There is need for increased focus on cancer prevention strategies in the African albino.
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Affiliation(s)
- F O A Ajose
- Consultant Physician Dermatologist, Department of Medicine, Lagos State University College of Medicine, Ikeja LAGOS Nigeria, Lagos, Nigeria
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16
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Gemmete JJ, Chaudhary N, Elias AE, Toma AK, Pandey AS, Parker RA, Davagnanam I, Maher CO, Brew S, Robertson F. Spinal dural arteriovenous fistulas: clinical experience with endovascular treatment as a primary therapy at 2 academic referral centers. AJNR Am J Neuroradiol 2013; 34:1974-9. [PMID: 23620076 DOI: 10.3174/ajnr.a3522] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spinal dural arteriovenous fistulas are a rare entity that, if left untreated, can lead to considerable morbidity with progressive spinal cord symptoms. The aim of this study was to evaluate the clinical outcome of patients with spinal dural arteriovenous fistulas that were primarily treated with endovascular embolization. MATERIALS AND METHODS A retrospective review was performed of all patients from 1997-2010 who underwent treatment at 2 academic referral centers for a spinal dural arteriovenous fistula. Follow-up was performed by clinical examination, and functional status was measured by use of the Aminoff-Logue Disability Scale, McCormick classification grading, and mRS scores. The nonparametric Wilcoxon signed rank test was used to compare pretreatment and posttreatment Aminoff-Logue Disability Scale gait and micturition scores, McCormick classification grading, and mRS scores. P values < .05 were considered significant. RESULTS A total of 38 patients were included. Five patients (2 endovascular, 3 surgical) were lost to follow-up and therefore were excluded from the analysis, 29 patients were initially treated from an endovascular approach (9 Onyx, 20 cyanoacrylate), and 4 patients were treated from a standard surgical approach. Five patients in the endovascular group subsequently underwent surgery for various reasons. The clinical improvements in the Aminoff-Logue Disability Scale gait and micturition scores, McCormick classification grading, and the mRS scores were statistically significant (P < .05, Wilcoxon signed rank test). CONCLUSIONS We conclude that endovascular treatment of spinal dural arteriovenous fistulas can result in good clinical outcomes. Surgery remains the treatment of choice when safe embolization of the proximal radicular draining vein cannot be obtained or because the shunting artery of the spinal dural arteriovenous fistula also supplies the anterior spinal, posterior spinal, or a radiculomedullary artery.
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17
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Alrawi YA, Parker RA, Harvey RC, Sultanzadeh SJ, Patel J, Mallinson R, Potter JF, Trepte NJB, Myint PK. Predictors of early mortality among hospitalized nursing home residents. QJM 2013; 106:51-7. [PMID: 23064829 DOI: 10.1093/qjmed/hcs188] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Emergency admissions from nursing homes (NHs) are associated with high mortality. Understanding the predictors of early mortality in these patients may guide clinicians in choosing appropriate site and level of care. METHODS We identified all consecutive admissions from NHs (all ages) to an Acute Medical Assessment Unit between January 2005 and December 2007. Analysis was performed at the level of the admission. The predictors of in-patient mortality at 7 days were examined using a generalized estimating equations analysis. RESULTS A total of 314 patients [32% male, mean age: 84.2 years (SD: 8.3 years)] were admitted during the study period constituting 410 emergency episodes. Twenty-three percent of admissions resulted in hospital mortality with 73% of deaths occurring within 1 week (50% within the first 3 days). For 7-day mortality outcome, patients with a modified early warning score (MEWS) of 4-5 on admission had 12 times the odds of death [95% confidence interval (CI) 1.40-103.56], whereas those with a score of ≥6 had 21 times the odds of death (95% CI 2.71-170.57) compared with those with a score of ≤1. An estimated glomerular filtration rate (eGFR) of 30-60 and <30 ml/min/m(2) was associated with nearly a 3-fold increase in the odds of death at 1 week (95% CI 1.10-7.97) and a 5-fold increase in the odds of death within 1 week (95% CI 1.75-14.96), respectively, compared with eGFR > 60 ml/min/m(2). C-reactive protein (CRP) >100 mg/l on admission was also associated with a 2.5 times higher odds of death (95% CI 1.23-4.95). Taking eight or more different medication items per day was associated with only a third of the odds of death (95% CI 0.09-0.98) compared with patients taking only three or fewer per day. CONCLUSION In acutely ill NH residents, MEWS is an important predictor of early hospital mortality and can be used in both the community and the hospital settings to identify patients whose death maybe predictable or unavoidable, thus allowing a more holistic approach to management with discussion with patient and relatives for planning of immediate care. In addition, CRP and eGFR levels on admission have also been shown to predict early hospital mortality in these patients and can be used in conjunction with MEWS in the same way to allow decision making on the appropriate level of care at the point of hospital admission.
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Affiliation(s)
- Y A Alrawi
- Academic Department of Medicine for the Elderly, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK.
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Davis TS, Parker RA, House PA, Bagley E, Wendelken S, Normann RA, Greger B. Spatial and temporal characteristics of V1 microstimulation during chronic implantation of a microelectrode array in a behaving macaque. J Neural Eng 2012; 9:065003. [PMID: 23186948 PMCID: PMC3521049 DOI: 10.1088/1741-2560/9/6/065003] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE It has been hypothesized that a vision prosthesis capable of evoking useful visual percepts can be based upon electrically stimulating the primary visual cortex (V1) of a blind human subject via penetrating microelectrode arrays. As a continuation of earlier work, we examined several spatial and temporal characteristics of V1 microstimulation. APPROACH An array of 100 penetrating microelectrodes was chronically implanted in V1 of a behaving macaque monkey. Microstimulation thresholds were measured using a two-alternative forced choice detection task. Relative locations of electrically-evoked percepts were measured using a memory saccade-to-target task. MAIN RESULTS The principal finding was that two years after implantation we were able to evoke behavioural responses to electric stimulation across the spatial extent of the array using groups of contiguous electrodes. Consistent responses to stimulation were evoked at an average threshold current per electrode of 204 ± 49 µA (mean ± std) for groups of four electrodes and 91 ± 25 µA for groups of nine electrodes. Saccades to electrically-evoked percepts using groups of nine electrodes showed that the animal could discriminate spatially distinct percepts with groups having an average separation of 1.6 ± 0.3 mm (mean ± std) in cortex and 1.0° ± 0.2° in visual space. Significance. These results demonstrate chronic perceptual functionality and provide evidence for the feasibility of a cortically-based vision prosthesis for the blind using penetrating microelectrodes.
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Affiliation(s)
- T S Davis
- Department of Bioengineering, University of Utah, UT, USA
| | - R A Parker
- Interdepartmental Program in Neuroscience, University of Utah, UT, USA
| | - P A House
- Department of Neurosurgery, University of Utah, UT, USA
| | - E Bagley
- Department of Bioengineering, University of Utah, UT, USA
| | - S Wendelken
- Department of Bioengineering, University of Utah, UT, USA
| | - R A Normann
- Department of Bioengineering, University of Utah, UT, USA
- Department of Ophthalmology and Visual Sciences, University of Utah, UT, USA
| | - B Greger
- Department of Bioengineering, University of Utah, UT, USA
- Department of Ophthalmology and Visual Sciences, University of Utah, UT, USA
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Abstract
CONTEXT A high prevalence of obesity has recently been reported in postmenopausal women with low trauma fracture, suggesting that higher bone mineral density (BMD) in obese individuals may not be protective against fracture. OBJECTIVE The aim of this study was to compare BMD and other risk factors for nonvertebral fracture in 1377 obese postmenopausal women. DESIGN Characteristics of obese women with and without incident nonvertebral fracture were investigated among the prospective cohort in the Study of Osteoporotic Fractures. SETTING The Study of Osteoporotic Fractures is a multicenter study of 9704 women (>99% Caucasian) aged 65 yr and over who were recruited between September 1986 and October 1988 from population-based listings at four U.S. clinical centers. MAIN OUTCOME MEASURE The main outcome measure was nonvertebral fracture. RESULTS BMD T-scores in the spine, femoral neck, and total hip were significantly lower in obese women who experienced fractures than in obese women without fracture: mean differences, -0.56 [95% confidence interval (CI) = -0.73 to -0.39], -0.46 (95% CI = -0.57 to -0.36), and -0.51 (95% CI = -0.62 to -0.39), respectively (P < 0.0001 for all). A previous history of fracture [odds ratio = 1.69 (95% CI = 1.33-2.14); P < 0.0001] and femoral neck BMD [1.62 (95% CI = 1.42-1.85) per sd decrease in BMD; P < 0.0001] were independently associated with incident nonvertebral fracture. CONCLUSIONS Obese postmenopausal women who sustain nonvertebral fractures have significantly lower BMD on average than obese women without fracture and are more likely to have a past history of fracture. Fractures in obese postmenopausal women thus exhibit some characteristics of fragility fractures.
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Affiliation(s)
- M O Premaor
- Department of Clinical Medicine, Federal University of Santa Maria, Santa Maria, Rio Grande do Sul 97105-900, Brazil.
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Abstract
REASONS FOR PERFORMING STUDY Assessing patients' quality of life (QOL) is a core part of clinical decision making. Various methodologies for assessing patients' QOL have been developed in human medicine and small animal veterinary disciplines. In contrast, the lack of aids for QOL assessment in equine veterinary practice leaves practitioners reliant on subjective assessments of QOL, which may be prone to avoidable errors. OBJECTIVES This paper suggests pragmatic ways in which QOL may be enhanced, while remaining appropriate for the time, financial and owner-based constraints within equine practice. METHODS Through interdisciplinary research, this paper identifies, adapts and applies insights from several areas of research and practical experience in order to develop an overarching approach to making QOL-based decisions in clinical cases. RESULTS The paper identifies 6 steps involved in QOL-based decision making and provides examples of how these steps may be practically applied. These include deciding what each clinician feels is important; deciding how to evaluate it, including taking owners' views into consideration; making decisions about each case and achieving the desired clinical outcomes. CONCLUSIONS Practitioners can draw their own conclusions on how they may improve QOL assessment in practice and may usefully share these with colleagues. Reporting cases and sharing practical examples of QOL tools used on the ground are vital to the development of this field and appropriate methodologies. POTENTIAL RELEVANCE Improvements in QOL assessment are relevant to all areas of equine veterinary practice, and several areas of research. Further research may develop QOL assessment in practice, but more important are the personal improvements that each practitioner may achieve.
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Affiliation(s)
- R A Parker
- Department of Clinical Veterinary Science, University of Bristol, Langford House, Langford, Bristol, UK
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Abstract
BACKGROUND High rates of fracture following liver transplantation were reported in earlier years, but the impact of subsequent changes in immune suppression and the introduction of bone-protective therapy on fracture rate have not been reported. AIM The aim of this study was to document clinical fracture incidence during the period 1998-2008 in a single transplant centre, following the introduction of a bone management protocol. DESIGN It was designed as a retrospective cohort. METHODS Records were retrieved from 531 of 592 eligible patients in an audit of all patients undergoing a first liver transplant during the 10-year period. All fractures were verified radiologically. RESULTS The mean follow-up period was 61.4 months. Prior to transplantation 5.6% of patients had a history of fracture. Incident clinical fractures following transplantation were recorded in just 15 (3.5%) patients. The most common fracture site was the spine and the median time from transplant to fracture was 26 months (range 2-83 months). CONCLUSION There was a low fracture rate in patients undergoing liver transplantation in this centre over the past 10 years. This rate is lower than that in previous reports, which is likely to reflect the use of lower doses of prednisolone for immune suppression and the administration of bone-protective therapy to high-risk patients.
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Affiliation(s)
- M O Premaor
- Department of Medicine, Addenbrooke's Hospital, Cambridgeshire CB2 0QQ, UK.
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Addley HC, Griffin N, Shaw AS, Mannelli L, Parker RA, Aitken S, Wood H, Davies S, Alexander GJ, Lomas DJ. Accuracy of hepatocellular carcinoma detection on multidetector CT in a transplant liver population with explant liver correlation. Clin Radiol 2011; 66:349-56. [PMID: 21295772 DOI: 10.1016/j.crad.2010.11.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 11/18/2010] [Accepted: 11/21/2010] [Indexed: 12/15/2022]
Abstract
AIM To evaluate the diagnostic accuracy of multidetector computed tomography (MDCT) for hepatocellular carcinoma (HCC) in cirrhotic patients undergoing liver transplantation. Secondary aims were to examine the effect of radiologist experience and lesion size on diagnostic accuracy. MATERIALS AND METHODS Thirty-nine patients (72% male with a mean age of 56.5 years) underwent liver transplantation following preoperative triple-phase MDCT examination of the liver. MDCT examinations were retrospectively independently reviewed by three radiologists for the presence and location of suspected HCCs, with the diagnostic confidence recorded using a five-point confidence scale. MDCT examinations were compared with explant specimens for histopathological correlation. RESULTS Histopathological results demonstrated 46 HCCs in 29 of the 39 patients. Analysis demonstrated a sensitivity of 65-75% and specificity of 47-88% for detection of HCC lesions. The sensitivity dropped to 48-57% for lesions of size ≤20mm. As the diagnostic confidence increased, there was a further decrease in the sensitivity (4-26%). The radiologist with the greatest number of years experience was found to have a significantly higher accuracy of detection of HCC lesions compared with the least experienced radiologist. CONCLUSION Larger lesion size of HCC and greater number of years experience of the radiologist resulted in significantly higher accuracy of HCC lesion detection. The overall sensitivity and specificity results for MDCT detection of HCC are comparable to previous helical CT imaging.
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Affiliation(s)
- H C Addley
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Addley HC, Griffin N, Shaw AS, Mannelli L, Parker RA, Aitken S, Wood H, Davies S, Alexander GJ, Lomas DJ. Accuracy of hepatocellular carcinoma detection on multidetector CT in a transplant liver population with explant liver correlation. Clin Radiol 2011. [PMID: 21295772 DOI: 10.1016/j.card.2010.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIM To evaluate the diagnostic accuracy of multidetector computed tomography (MDCT) for hepatocellular carcinoma (HCC) in cirrhotic patients undergoing liver transplantation. Secondary aims were to examine the effect of radiologist experience and lesion size on diagnostic accuracy. MATERIALS AND METHODS Thirty-nine patients (72% male with a mean age of 56.5 years) underwent liver transplantation following preoperative triple-phase MDCT examination of the liver. MDCT examinations were retrospectively independently reviewed by three radiologists for the presence and location of suspected HCCs, with the diagnostic confidence recorded using a five-point confidence scale. MDCT examinations were compared with explant specimens for histopathological correlation. RESULTS Histopathological results demonstrated 46 HCCs in 29 of the 39 patients. Analysis demonstrated a sensitivity of 65-75% and specificity of 47-88% for detection of HCC lesions. The sensitivity dropped to 48-57% for lesions of size ≤20mm. As the diagnostic confidence increased, there was a further decrease in the sensitivity (4-26%). The radiologist with the greatest number of years experience was found to have a significantly higher accuracy of detection of HCC lesions compared with the least experienced radiologist. CONCLUSION Larger lesion size of HCC and greater number of years experience of the radiologist resulted in significantly higher accuracy of HCC lesion detection. The overall sensitivity and specificity results for MDCT detection of HCC are comparable to previous helical CT imaging.
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Affiliation(s)
- H C Addley
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Abstract
Various operational aspects of the Spacelab 1 mission are reviewed by the four payload crew members. Two-shift operations, voice communication with ground investigators, joint participation in experiment activity, Spacelab performance, and recent advances are discussed.
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Premaor MO, Pilbrow L, Tonkin C, Adams M, Parker RA, Compston J. Low rates of treatment in postmenopausal women with a history of low trauma fractures: results of audit in a Fracture Liaison Service. QJM 2010; 103:33-40. [PMID: 19864348 DOI: 10.1093/qjmed/hcp154] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A past history of low trauma fracture is a strong risk factor for future fractures in postmenopausal women and national guidance recommends treatment in the majority of such women AIM To establish the prevalence of bone protective therapy use in postmenopausal women with a history of low trauma fracture Design and METHODS Clinical audit of 1641 postmenopausal women presenting with a low trauma fracture to the Fracture Liaison Service at Addenbrooke's Hospital, Cambridge between January 2006 and December 2007. RESULTS A total of 526 (31%) women presenting with a fracture had a past history of fracture, defined as a low trauma fracture after the age of 45 years. The wrist was the most common site of previous fracture, followed by hip, hand or foot, lower leg and humerus. Of these women, only 27.6% were receiving bone protective therapy with a bisphosphonate (89%) or other medication. Calcium and vitamin D supplements were received by 35.6%. The highest rates of treatment were seen for spine and hip fracture (61.9 and 49.3%, respectively). Only 45.1% of women aged 75 years and over with a previous history of fracture were receiving bone protective therapy. CONCLUSION The results of our audit demonstrate low rates of treatment in postmenopausal women with a history of low trauma fracture. Better education of healthcare professionals, more consistent recording of fractures in primary care and the use of clearly defined care pathways that involve patients and their carers provide rational approaches to reducing this care gap.
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Affiliation(s)
- M O Premaor
- Department of Medicine, University of Cambridge, Cambridge, UK.
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Rosen HN, Parker RA, Greenspan SL, Iloputaife ID, Bookman L, Chapin D, Perlmutter I, Kessel B, Qvist P, Rosenblatt M. Evaluation of ability of biochemical markers of bone turnover to predict a response to increased doses of HRT. Calcif Tissue Int 2004; 74:415-23. [PMID: 14961215 DOI: 10.1007/s00223-003-0114-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2003] [Accepted: 10/20/2003] [Indexed: 10/26/2022]
Abstract
Antiresorptive therapy is usually given in a fixed dose, and we hypothesized that some patients receiving standard doses of hormone replacement therapy (HRT) might benefit from a higher dose, particularly if their bone turnover decreases after increasing the dose of HRT. Eighty-eight women who had been receiving standard-dose (0.625 mg/day) conjugated equine estrogens (CEE) for at least one year were randomized to take either standard-dose (0.625 mg/day, n = 36) or high-dose (1.25 mg/day, n = 52) therapy. Subjects with a uterus were allowed to take either 10 mg of medroxyprogesterone cyclically or 5 mg daily, according to personal preference. Bone Mineral Density (BMD) and biochemical markers of bone turnover were followed for 2 years. Mean bone turnover decreased significantly (-4.1% to -19.1%) after 6 months of high-dose CEE. Decreases in serum BSAP (bone-specific alkaline phosphatase) and serum or urine NTX ( N-terminal telopeptide crosslink of type I collagen) on high-dose therapy were not predictive of an improvement in BMD, but a decrease in serum CrossLaps did predict an improvement in BMD. Mean change in BMD in subjects with a significant decrease in serum CrossLaps at the anteroposterior spine was 3.1% +/- 3.9% versus 1.2% +/- 2.9% for subjects with no significant change in CrossLaps, P < 0.02. There was, however, a wide range of changes in BMD in patients with or without a significant change in CTX on high-dose HRT, making it impossible to predict an improvement in BMD based on an individual's changes in turnover. Measuring of bone density and bone turnover with better precision might be more successful in guiding individual dosing of antiresorptive therapy.
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Affiliation(s)
- H N Rosen
- Charles A. Dana Research Institute and the Harvard-Thorndike Laboratory of the Beth Israel Deaconess Medical Center, Department of Medicine, Division of Endocrinology, Harvard Medical School, Boston, MA 02215, USA.
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Schwartz JG, Johnson RB, Aepfelbacher FC, Parker JA, Chen L, Azar RR, Parker RA, Danias PG. Sensitivity, specificity and accuracy of stress SPECT myocardial perfusion imaging for detection of coronary artery disease in the distribution of first-order branch vessels, using an anatomical matching of angiographic and perfusion data. Nucl Med Commun 2003; 24:543-9. [PMID: 12717072 DOI: 10.1097/00006231-200305000-00010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We sought to investigate the utility of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) for the identification of coronary artery disease (CAD) in the distribution of first-order branch vessels. We evaluated 135 consecutive patients with coronary angiography and stress SPECT MPI. We anatomically matched angiography and SPECT to assess the sensitivity, specificity and accuracy of SPECT MPI for the detection of CAD in the distribution of first-order branches. Subgroup analysis for stress test performance and previous coronary artery bypass grafting (CABG) was also performed. The sensitivity, specificity and accuracy of stress SPECT MPI for the detection of CAD in the distribution of first-order branch vessels were all 67%. For isolated branch vessel CAD, stress SPECT MPI had a sensitivity of 44%. In patients without CABG, the sensitivity, specificity and accuracy for the detection of CAD in the distribution of first-order branch vessels were 71%, 67% and 68%, compared with 60%, 67% and 64% for patients with CABG. The sensitivity for isolated branch vessel CAD was 50% for patients without CABG, but only 29% for patients with CABG. The sensitivity and specificity for CAD in the distribution of branch vessels were similar for all patients for all stress test modalities and heart rate response (sensitivity, 64-69%; specificity, 61-69%). Stress SPECT MPI offers intermediate sensitivity, specificity and accuracy for the detection of CAD in the distribution of first-order coronary artery branch vessels. However, for isolated branch vessel CAD, stress SPECT has a lower sensitivity, particularly in patients with previous CABG.
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Affiliation(s)
- J G Schwartz
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
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Gaus SE, Strecker RE, Tate BA, Parker RA, Saper CB. Ventrolateral preoptic nucleus contains sleep-active, galaninergic neurons in multiple mammalian species. Neuroscience 2003; 115:285-94. [PMID: 12401341 DOI: 10.1016/s0306-4522(02)00308-1] [Citation(s) in RCA: 215] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The ventrolateral preoptic nucleus (VLPO) is a group of sleep-active neurons that has been identified in the hypothalamus of rats and is thought to inhibit the major ascending monoaminergic arousal systems during sleep; lesions of the VLPO cause insomnia. Identification of the VLPO in other species has been complicated by the lack of a marker for this cell population, other than the expression of Fos during sleep. We now report that a high percentage of the sleep-active (Fos-expressing) VLPO neurons express mRNA for the inhibitory neuropeptide, galanin, in nocturnal rodents (mice and rats), diurnal rodents (degus), and cats. A homologous (i.e. galanin mRNA-containing cell group) is clearly distinguishable in the ventrolateral region of the preoptic area in diurnal and nocturnal monkeys, as well as in humans. Galanin expression may serve to identify sleep-active neurons in the ventrolateral preoptic area of the mammalian brain. The VLPO appears to be a critical component of sleep circuitry across multiple species, and we hypothesize that shrinkage of the VLPO with advancing age may explain sleep deficits in elderly humans.
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Affiliation(s)
- S E Gaus
- Program in Neuroscience, Harvard Medical School and Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
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Abstract
BACKGROUND A number of reports have suggested that there are substantial racial differences in the frequency of gastro-oesophageal reflux disease and its complications, but few studies have compared directly the frequency of this disorder amongst different racial groups. AIM To explore the racial differences in the frequency of gastro-oesophageal reflux disease and its complications. METHODS We reviewed endoscopy reports and medical records for data on race and complications of gastro-oesophageal reflux disease in 2,477 consecutive patients who had endoscopic examinations at the general endoscopy unit of an academic hospital. In addition, we prospectively interviewed 129 out-patients attending general medical clinics in the hospital and in an Asian community health centre in Boston to obtain data on race and gastro-oesophageal reflux disease symptoms. RESULTS One or more gastro-oesophageal reflux disease complications (peptic oesophageal ulcer, stricture or Barrett's oesophagus) were observed in 267 of 2,174 white patients (12.3%), seven of 249 black patients (2.8%), one of 21 West Asian patients (4.8%) and none of 33 East Asian patients seen at the general endoscopy unit (P < 0.001); 34.6% of whites, 46.1% of blacks and 2.6% of East Asian patients interviewed claimed that they had heartburn (P < 0.01), but the term 'heartburn' was understood by only 34.6%, 53.8% and 13.2% of whites, blacks and East Asians, respectively (P < 0.01). CONCLUSIONS Asian patients in Boston infrequently complain of heartburn, whereas heartburn is commonly reported by both white and black patients. Many patients do not understand the meaning of the term heartburn, however, and so physicians should be cautious when using the term during patient interviews. Complicated gastro-oesophageal reflux disease appears to be predominantly a disorder of whites.
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Abstract
BACKGROUND Inclusion body myositis (IBM) remains without effective therapy. As anabolic steroids have myotrophic properties, the authors studied whether a synthetic androgen, oxandrolone, would have efficacy in IBM. METHODS A double-blind, placebo-controlled, crossover design was used. Patients received oxandrolone or placebo for 12 weeks followed by a minimum 2-month washout period, followed by 12 weeks of the alternative treatment. Maximal voluntary isometric contraction testing (MVICT), manual muscle testing (MMT), and functional performance testing were obtained before and after each treatment period, with the whole-body MVICT score as the primary outcome measure. RESULTS Of 19 patients enrolled, 16 (14 men, 2 women; median age 68.5 years) had complete data for at least the first treatment period, with 13 completing the entire study. Whole-body MVICT improved by a median of 15.5 kg with drug and 4.1 kg with placebo (p = 0.06), whereas MMT demonstrated a median increase of 2.0 Medical Research Council points with drug and 0.9 point with placebo (p = 0.33). Upper-extremity MVICT demonstrated a significant treatment effect, with strength increasing a median 6.3 kg with drug vs 2.5 kg with placebo (p = 0.006). Stair climbing also increased a median of 1 step on average with drug versus no change with placebo (p < 0.001). Minimal adverse effects occurred. CONCLUSIONS Oxandrolone had a borderline significant effect in improving whole-body strength and a significant effect in improving upper-extremity strength as measured by MVICT. Given these findings, further study of this drug, possibly in combination with an immunomodulating agent, is warranted.
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Affiliation(s)
- S B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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Bolus SA, Katz JN, Parker RA, Bierbaum BE, Connolly CE, lversen MD, Bischoff H, Rooks DS. THE EFFECTS OF PREOPERATIVE EXERCISE ON FUNCTIONAL STATUS IN PERSONS UNDERGOING TOTAL HIP ARTHROPLASTY. J Geriatr Phys Ther 2002. [DOI: 10.1519/00139143-200225030-00041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cramer SC, Fray E, Tievsky A, Parker RA, Riskind PN, Stein MC, Wedeen V, Rosen BR. Changes in motor cortex activation after recovery from spinal cord inflammation. Mult Scler 2001; 7:364-70. [PMID: 11795457 DOI: 10.1177/135245850100700604] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diseases of the spinal cord are associated with reactive changes in cerebral cortex organization. Many studies in this area have examined spinal cord conditions not associated with recovery, making it difficult to consider the value of these cortical events in the restoration of neurological function. We studied patients with myelitis, a syndrome of transient spinal cord inflammation, in order to probe cortical changes that might contribute to recovery after disease of the spinal cord. Seven patients, each of whom showed improvement in hand motor function after a diagnosis of myelitis involving cervical spinal cord, were clinically evaluated then studied with functional MRI. During right and left index finger tapping, activation volumes were assessed in three cortical motor regions within each hemisphere. Results were compared with findings in nine control subjects. Compared to the control group, myelitis patients had larger activation volumes within contralateral sensorimotor as well as contralateral premotor cortex. The degree of daily hand use showed a significant correlation with the volume of activation in contralateral sensorimotor cortex. Recovery from myelitis is associated with an enlarged activation volume in contralateral motor cortices. This change in motor cortex function is related to behavioral experience, and thus may contribute to motor improvement. The expanded activation in motor cortex, seen with several forms of spinal cord insult may have maximal utility when corticospinal tract axons are preserved.
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Affiliation(s)
- S C Cramer
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Aepfelbacher FC, Johnson RB, Schwartz JG, Chen L, Parker RA, Parker JA, Danias PG. Validation of a model of left ventricular segmentation for interpretation of SPET myocardial perfusion images. Eur J Nucl Med 2001; 28:1624-9. [PMID: 11702103 DOI: 10.1007/s002590100618] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Several models of left ventricular segmentation have been developed that assume a standard coronary artery distribution, and are currently used for interpretation of single-photon emission tomography (SPET) myocardial perfusion imaging. This approach has the potential for incorrect assignment of myocardial segments to vascular territories, possibly over- or underestimating the number of vessels with significant coronary artery disease (CAD). We therefore sought to validate a 17-segment model of myocardial perfusion by comparing the predefined coronary territory assignment with the actual angiographically derived coronary distribution. We examined 135 patients who underwent both coronary angiography and stress SPET imaging within 30 days. Individualized coronary distribution was determined by review of the coronary angiograms and used to identify the coronary artery supplying each of the 17 myocardial segments of the model. The actual coronary distribution was used to assess the accuracy of the assumed coronary distribution of the model. The sensitivities and specificities of stress SPET for detection of CAD in individual coronary arteries and the classification regarding perceived number of diseased coronary arteries were also compared between the two coronary distributions (actual and assumed). The assumed coronary distribution corresponded to the actual coronary anatomy in all but one segment (#3). The majority of patients (80%) had 14 or more concordant segments. Sensitivities and specificities of stress SPET for detection of CAD in the coronary territories were similar, with the exception of the RCA territory, for which specificity for detection of CAD was better for the angiographically derived coronary artery distribution than for the model. There was 95% agreement between assumed and angiographically derived coronary distributions in classification to single- versus multi-vessel CAD. Reassignment of a single segment (segment #3) from the LCX to the LAD territory further improved the model's fit with the anatomic data. It is concluded that left ventricular segmentation using a model with assumed coronary artery distribution is valid for interpretation of SPET myocardial perfusion imaging.
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Affiliation(s)
- F C Aepfelbacher
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
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Parker RA, Regan MM, Reimann KA. Variability of viral load in plasma of rhesus monkeys inoculated with simian immunodeficiency virus or simian-human immunodeficiency virus: implications for using nonhuman primate AIDS models to test vaccines and therapeutics. J Virol 2001; 75:11234-8. [PMID: 11602764 PMCID: PMC114704 DOI: 10.1128/jvi.75.22.11234-11238.2001] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Viral RNA level in plasma is a sensitive experimental endpoint for evaluating the efficacy of AIDS vaccines or therapies in nonhuman primates. By quantifying viral RNA in the plasma of 77 rhesus monkeys for 10 weeks after inoculation with simian-human immunodeficiency virus 89.6P (SHIV-89.6P) or simian immunodeficiency virus mac 251 (SIVmac 251), we estimated variability in three viral load (VL) measures: peak VL, the postacute set point VL, and VL decline from peak. Such estimates of biological variability are essential for determining the number of animals needed per group and may be helpful for selecting the most appropriate measure to use as the experimental endpoint. Peak VL was positively correlated with set point VL for both viruses. Variability (standard deviation) was substantially higher in monkeys infected with SIVmac 251 than in those infected with SHIV-89.6P for set point VL and VL decline. The variability of peak VL was less than one-half that of set point VL variability and only about two-thirds of that of VL decline, implying that the same treatment-related difference in peak VL could be detected with fewer animals than set point VL or VL decline. Thus, differences in VL variability over the course of infection and between viruses need to be considered when designing studies using the nonhuman primate AIDS models.
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Affiliation(s)
- R A Parker
- Biometrics Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Toyoda Y, Khan S, Chen W, Parker RA, Levitsky S, McCully JD. Effects of NHE-1 inhibition on cardioprotection and impact on protection by K/Mg cardioplegia. Ann Thorac Surg 2001; 72:836-43; discussion 843-4. [PMID: 11565667 DOI: 10.1016/s0003-4975(01)02823-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Cardiac sodium hydrogen exchanger isoform-1 (NHE-1) activity during ischemia/reperfusion contributes to myocardial injury. The effects of NHE-1 inhibition during ischemia or reperfusion and on the protection afforded by K/Mg cardioplegia was unknown. METHODS Rabbit hearts were used for Langendorff perfusion. Control hearts were perfused for 180 minutes. Global ischemia (GI) hearts received 30 minutes normothermic global ischemia and 120 minutes reperfusion. K/Mg hearts received cardioplegia 5 minutes before ischemia. Separate groups of GI and K/Mg hearts received the NHE-1 inhibitor, HOE-642, before ischemia (HOE-642-I), at the immediate start of reperfusion (HOE-642-R), or both before ischemia and at the immediate start of reperfusion (HOE-642-IR). RESULTS Left ventricular peak developed pressure was significantly increased in HOE-I, HOE-R, and HOE-IR throughout reperfusion (p < 0.05 versus GI). Infarct size was significantly decreased (p < 0.05 versus GI) in all groups, but was significantly increased in HOE-R as compared with HOE-IR (p < 0.05). NHE-1 inhibition with K/Mg cardioplegia significantly decreased left ventricular peak developed pressure after 90 minutes of reperfusion (p < 0.05 versus K/Mg), with no significant effect on infarct size. CONCLUSIONS NHE-1 inhibition used alone provides cardioprotection with optimal effects being observed with HOE-IR. NHE-1 inhibition with K/Mg cardioplegia decreases postischemic functional recovery during late reperfusion.
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Affiliation(s)
- Y Toyoda
- Division of Cardiothoracic Surgery and Biometrics Center, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02115, USA
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Parker RA, Hartman EE. A 26-year-old woman with shoulder pain, 1 year later. JAMA 2001; 285:3140. [PMID: 11427144 DOI: 10.1001/jama.285.24.3140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Stoch SA, Parker RA, Chen L, Bubley G, Ko YJ, Vincelette A, Greenspan SL. Bone loss in men with prostate cancer treated with gonadotropin-releasing hormone agonists. J Clin Endocrinol Metab 2001; 86:2787-91. [PMID: 11397888 DOI: 10.1210/jcem.86.6.7558] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Prostate cancer is the most common visceral malignancy in men. As the tumor is testosterone dependent, a frequent treatment modality involves therapy with GnRH agonists (GnRH-a) resulting in hypogonadism. Because testosterone is essential for the maintenance of bone mass in men, we postulated that GnRH-a therapy would negatively impact skeletal integrity. We compared bone mineral density (BMD), biochemical markers of bone turnover, and body composition in 60 men with prostate cancer (19 men receiving GnRH-a therapy and 41 eugonadal men) and BMD in 197 community-living healthy controls of similar age. BMD was assessed by dual energy x-ray absorptiometry and ultrasound. Biochemical markers of bone turnover, included markers of bone resorption (urinary N-telopeptide) and bone formation markers (bone-specific alkaline phosphatase and osteocalcin). Body composition (total body fat and lean body mass) was assessed by dual energy x-ray absorptiometry. Significantly lower BMD was found at the lateral spine (0.69 +/- 0.17 vs. 0.83 +/- 0.20 g/cm(2); P < 0.01), total hip (0.94 +/- 0.14 vs. 1.05 +/- 0.16 g/cm(2); P < 0.05), and forearm (0.67 +/- 0.11 vs. 0.78 +/- 0.07 g/cm(2); P < 0.01) in men receiving GnRH-a compared with the eugonadal men with prostate cancer. Significant differences were also seen at the total body, finger, and calcaneus (all P < 0.01). BMD values in eugonadal men with prostate cancer and healthy controls were similar. Markers of bone resorption (urinary N-telopeptide) and bone formation (bone-specific alkaline phosphatase) were elevated in men receiving GnRH-a therapy compared with those in eugonadal men with prostate cancer. Men receiving GnRH-a also had a higher percent total body fat (29 +/- 5% vs. 25 +/- 5%; P < 0.01) and lower percent lean body weight (71 +/- 5% vs. 75 +/- 5%; P < 0.01) compared with eugonadal men with prostate cancer. In conclusion, men with prostate cancer receiving androgen deprivation therapy have a significant decrease in bone mass and increase in bone turnover, thus placing them at increased risk of fracture.
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Affiliation(s)
- S A Stoch
- Division of Bone and Mineral Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Parker RA, Hartman EE. A 36-year-old woman who smokes cigarettes, 1 year later. JAMA 2001; 285:2636. [PMID: 11368738 DOI: 10.1001/jama.285.20.2636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
Postmenopausal women who choose hormone replacement therapy (HRT) often discontinue this therapy within 1 year. Few studies have considered why older women (aged > or =65 years) discontinue therapy. To investigate this question and its relationship to HRT-related side effects, we analyzed data collected during the 3-month open-label (active HRT and alendronate placebo) run-in phase of a clinical trial for osteoporosis prevention and treatment in older women. Among women discontinuing the trial, we ascertained a primary reason based on the patients' records and classified it as related or unrelated to HRT. The incidence of specific HRT-related side effects reported during the run-in phase was abstracted from the trial database and compared between patients continuing in the trial and those discontinuing for HRT-related reasons. Of the 485 women who began the 3-month run-in phase, 112 (23%) discontinued the trial. Specifically, 73 (15%) women discontinued for reasons considered HRT related. Breast swelling/tenderness (26 women) and bloating (9 women) were more often primary reasons for discontinuation than were bleeding or spotting (7 women). Comparing all reported side effects, bloating was more common in women discontinuing because of HRT than in women continuing in the trial (18% versus 3%, p < or = 0.001), whereas other complaints were similar or lower: breast swelling/tenderness (59% versus 67%, p > 0.05), bleeding (16% versus 17%, p > 0.05), spotting (23% versus 41%, p < or = 0.05). Bloating, of which women discontinuing complained significantly more often, and breast swelling/tenderness, the most frequently cited primary reason for discontinuation, may be more important factors than bleeding or spotting in an older woman's decision to discontinue HRT.
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Affiliation(s)
- M M Regan
- Charles A. Dana Research Institute, Harvard-Thorndike General Clinical Research Centre, Beth Israel Deaconess Medical Centre and Harvard Medical School, Boston, Massachusetts, USA
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Peebles RS, Sheller JR, Collins RD, Jarzecka AK, Mitchell DB, Parker RA, Graham BS. Respiratory syncytial virus infection does not increase allergen-induced type 2 cytokine production, yet increases airway hyperresponsiveness in mice. J Med Virol 2001; 63:178-88. [PMID: 11170055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Severe respiratory syncytial virus (RSV)-induced disease is associated with childhood asthma and atopy. We combined murine models of allergen-sensitization and RSV infection to explore the interaction of allergic and virus-induced airway inflammation and its impact on airway hyperresponsiveness (AHR). We found that RSV infection during ova-sensitization (OVA/RSV) increased and prolonged AHR compared to mice only RSV-infected (RSV) or ova-sensitized (OVA). AHR is known to be associated with an increase in Type 2 cytokines (IL-4, IL-5, and IL-13) in allergen-sensitized mice. Therefore, we hypothesized that RSV-induced enhancement of AHR was a result of potentiating the Type 2 cytokine profile promoted by ova-sensitization. Surprisingly, we found that Type 2 cytokines induced by ova-sensitization were not increased by RSV infection despite the increase in AHR, and in some cases were diminished. RNAse protection assay revealed no difference in IL-4 and IL-5 mRNA levels between the OVA and OVA/RSV groups, and IL-13 mRNA was significantly decreased in the OVA/RSV mice compared to the OVA group. Flow cytometric analysis of Type 2 cytokines demonstrated the same frequency of IL-4 and IL-5 production in lung-derived T lymphocytes from the OVA/RSV and OVA groups. Direct cytokine ELISA measurements of lung supernatant showed the level of IL-13 was significantly decreased in the OVA/RSV group compared to OVA mice, while there was no difference in either IL-4 or IL-5 between these two groups. These data indicate that the enhanced and prolonged AHR caused by the interaction of allergic airway inflammation and virus-induced immune responses is a complex process that can not be explained simply by augmented production of Type 2 cytokines.
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Affiliation(s)
- R S Peebles
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-2582, USA
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Greenspan SL, von Stetten E, Emond SK, Jones L, Parker RA. Instant vertebral assessment: a noninvasive dual X-ray absorptiometry technique to avoid misclassification and clinical mismanagement of osteoporosis. J Clin Densitom 2001; 4:373-80. [PMID: 11748342 DOI: 10.1385/jcd:4:4:373] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2000] [Revised: 04/19/2000] [Accepted: 04/24/2001] [Indexed: 11/11/2022]
Abstract
The presence of a vertebral fracture significantly increases the risk of future fracture, classifies a patient with "clinical" osteoporosis, and usually results in treatment for osteoporosis. However, the majority of vertebral fractures are silent, and lateral X-rays (the standard method for identification) are not routinely obtained. Instant vertebral assessment (IVA), a technology that utilizes dual X-ray absorptiometry (DXA), provides rapid assessment of vertebral fractures and is highly correlated with vertebral fractures, as assessed on standard lateral spine X-rays. To assess the role of IVA in patient management, we examined standard bone mineral density (BMD) of the spine, total hip, and femoral neck and spine IVA by DXA in 482 participants screened for an osteoporosis study, who had no previous knowledge of vertebral fractures. Using World Health Organization (WHO) guidelines, subjects were classified using BMD at the spine, total hip, femoral neck, or any combination of these central sites. In addition, we considered subjects as osteoporotic if they had vertebral fractures independent of low bone density. We found that vertebral fractures assessed by IVA were present in 18.3% of asymptomatic postmenopausal women recruited for this study. The sensitivity of BMD alone to diagnose osteoporosis based on either a vertebral fracture or low BMD using WHO criteria ranged from 40 to 74%. This means that between 26 and 60% of osteoporotic individuals could have potentially been missed. Furthermore, 11.0-18.7% of clinically osteoporotic individuals would have been classified as normal by BMD criteria alone. We conclude that IVA is a useful adjunct in the clinical identification of osteoporosis and may prevent mismanagement of osteoporotic patients.
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Affiliation(s)
- S L Greenspan
- University of Pittsburgh Medical Center, Osteoporosis Prevention and Treatment Center, Lilliane S. Kaufmann Medical Building, Suite 1110, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Abstract
PURPOSE To compare the stress experienced by women who had false-positive screening mammograms and had undergone immediate on-site diagnostic imaging evaluation with that experienced by those who had been recalled for subsequent imaging. MATERIALS AND METHODS A retrospective survey was mailed to women with false-positive screening mammograms that had proved negative or benign at diagnostic imaging. The women were divided into (a) those who had undergone diagnostic imaging during the same appointment as their screening examination and (b) those who had returned at a later date for work-up. The survey included questions about stress that was related to the screening and diagnostic experiences, how subjects had been notified about screening results, and their breast health histories. RESULTS From the group that had undergone immediate work-up (n = 100), 50 eligible surveys were received; 71 were received from women who had undergone later work-ups (n = 176). The self-reported overall stress was significantly greater (P =.027) in the group recalled for subsequent diagnostic imaging. Among all respondents, stress from a false-positive screening result was greatest in women younger than 50 years of age with a positive first-degree family history of breast cancer. CONCLUSION Providing immediate on-site diagnostic evaluation can reduce the stress of a false-positive screening mammogram.
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Affiliation(s)
- K K Lindfors
- School of Medicine, Department of Radiology, University of California, Davis, 4860 Y St, Ste 3100, Sacramento, CA 95817, USA.
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Affiliation(s)
- R A Parker
- Beth Israel Deaconess Medical Center; Boston, MA 02215, USA.
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Toyoda Y, Friehs I, Parker RA, Levitsky S, McCully JD. Differential role of sarcolemmal and mitochondrial K(ATP) channels in adenosine-enhanced ischemic preconditioning. Am J Physiol Heart Circ Physiol 2000; 279:H2694-703. [PMID: 11087223 DOI: 10.1152/ajpheart.2000.279.6.h2694] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Adenosine-enhanced ischemic preconditioning (APC) extends the protection afforded by ischemic preconditioning (IPC) by both significantly decreasing infarct size and significantly enhancing postischemic functional recovery. The purpose of this study was to determine whether APC is modulated by ATP-sensitive potassium (K(ATP)) channels and to determine whether this modulation occurs before ischemia or during reperfusion. The role of K(ATP) channels before ischemia (I), during reperfusion (R), or during ischemia and reperfusion (IR) was investigated using the nonspecific K(ATP) blocker glibenclamide (Glb), the mitochondrial (mito) K(ATP) channel blocker 5-hydroxydecanoate (5-HD), and the sarcolemmal (sarc) K(ATP) channel blocker HMR-1883 (HMR). Infarct size was significantly increased (P < 0.05) in APC hearts with Glb-I, Glb-R, and 5-HD-I treatment and partially with 5-HD-R. Glb-I and Glb-R treatment significantly decreased APC functional recovery (P < 0.05 vs. APC), whereas 5-HD-I and 5-HD-R had no effect on APC functional recovery. HMR-IR significantly decreased postischemic functional recovery (P < 0.05 vs. APC) but had no effect on infarct size. These data indicate that APC infarct size reduction is modulated by mitoK(ATP) channels primarily during ischemia and suggest that functional recovery is modulated by sarcK(ATP) channels during ischemia and reperfusion.
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Affiliation(s)
- Y Toyoda
- Division of Cardiothoracic Surgery and Biometrics Center, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02115, USA
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Abstract
BACKGROUND Adenosine-enhanced ischemic preconditioning (APC) extends the protection afforded by ischemic preconditioning (IPC) by both significantly decreasing infarct size and significantly enhancing post-ischemic functional recovery. In this study, the anti-infarct effects and the anti-stunning effects of APC in contributing to enhanced post-ischemic functional recovery were determined and compared with IPC. METHODS AND RESULTS Sheep (n=96) were subjected to 15, 30, 45, or 60 minutes of regional ischemia and 120 minutes of reperfusion. IPC hearts received 5 minutes of regional ischemia and 5 minutes of reperfusion before ischemia/reperfusion. APC hearts received a bolus injection of adenosine coincident with IPC. Adenosine hearts (ADO) received a bolus injection of adenosine before ischemia/reperfusion. Regional ischemia (RI) hearts received no pretreatment. Infarct size/area at risk was determined by tetrazolium staining. Regional myocardial function was determined by sonomicrometry. Segment shortening after 15 minutes of ischemia in which no infarct was incurred was 32. 1+/-10.6% in RI, 70.6+/-8.5% in IPC, and 77.4+/-6.0% in APC hearts. Segment shortening after 30 minutes of ischemia was 60.7+/-6.3% in APC hearts (P:<0.05 versus RI, ADO, IPC) but was <37% in all other groups. Infarct size/area at risk after 30 and 60 minutes of ischemia was, respectively, 25.8+/-5.7% and 49.8+/-6.0% in RI, 12. 9+/-3.0% and 29.2+/-5.0% in ADO, 11.6+/-2.4% and 24.6+/-2.7% in IPC, and 5.1+/-1.6% and 12.4+/-2.0% in APC hearts (P:<0.05 versus RI, ADO, IPC). CONCLUSIONS APC and IPC exhibit anti-infarct and anti-stunning effects in the ovine heart, but these effects are rapidly diminished with IPC. APC significantly extends these effects, providing for significantly enhanced infarct size reduction and post-ischemic functional recovery (P:<0.05 versus IPC).
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Affiliation(s)
- Y Toyoda
- Division of Cardiothoracic Surgery and Biometrics Center, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02115, USA
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Greenspan SL, Rosen HN, Parker RA. Early changes in serum N-telopeptide and C-telopeptide cross-linked collagen type 1 predict long-term response to alendronate therapy in elderly women. J Clin Endocrinol Metab 2000; 85:3537-40. [PMID: 11061497 DOI: 10.1210/jcem.85.10.6911] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The aim of this study was to determine whether early changes in serum markers of bone resorption could predict long-term responses in bone mineral density (BMD) after alendronate therapy in elderly women. One hundred and twenty women (mean age, 70 yr) were randomized to alendronate or placebo in this double blind, placebo-controlled clinical trial for 2.5 yr. Outcome measures were hip and spine BMD and biochemical markers of bone resorption, including serum N-telopeptide and C-telopeptide cross-linked collagen type I (NTx and CTx, respectively). Serum NTx and CTx were highly correlated at baseline (r = 0.73; P < 0.001) and remained so throughout the study (range, r = 0.36-0.56; all P < 0.05). After treatment with alendronate, serum NTx decreased 30.4+/-16.0% at 6 months, reaching a nadir of -36.7+/-18.0% by 24 months (P < 0.001). Serum CTx decreased 43.5+/-67.0% at 6 months and continued to decrease to 67.3+/-19.3% at 2.5 yr (P < 0.001). Moreover, decreases in serum NTx and CTx at 6 months were correlated with long-term improvements in vertebral BMD at 2.5 yr in patients receiving alendronate therapy (NTx: r = -0.42; CTx: r = -0.31; both P < 0.05). We conclude that early changes in serum NTx and CTx, markers of bone resorption, predict long-term changes in vertebral BMD in elderly women receiving alendronate therapy and provide a useful tool to assess skeletal health.
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Affiliation(s)
- S L Greenspan
- Department of Medicine, University of Pittsburgh Medical Center, Pennsylvania 15213, USA.
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