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Uwins C, Assalaarachchi H, Bennett K, Read J, Tailor A, Crawshaw J, Chatterjee J, Ellis P, Skene SS, Michael A, Butler-Manuel S. MIRRORS: a prospective cohort study assessing the feasibility of robotic interval debulking surgery for advanced-stage ovarian cancer. Int J Gynecol Cancer 2024:ijgc-2024-005265. [PMID: 38561194 DOI: 10.1136/ijgc-2024-005265] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE To establish the feasibility and safety of robotic interval debulking surgery following the MIRRORS protocol (robot-assisted laparoscopic assessment prior to robotic or open surgery) in women with advanced-stage ovarian cancer. MIRRORS is the first of three planned trials: MIRRORS, MIRRORS-RCT (pilot), and MIRRORS-RCT. METHODS The participants were patients with stage IIIc-IVb epithelial ovarian cancer undergoing neo-adjuvant chemotherapy, suitable for interval debulking surgery with a pelvic mass ≤8 cm. The intervention was robot-assisted laparoscopic assessment prior to robotic or open interval debulking surgery (MIRRORS protocol). The primary outcome was feasibility of recruitment, and the secondary outcomes were quality of life (EORTC QLQC30/OV28, HADS questionnaires), pain, surgical complications, complete cytoreduction rate (%), conversion to open surgery (%), and overall and progression-free survival at 1 year. RESULTS Overall, 95.8% (23/24) of patients who were eligible were recruited. Median age was 68 years (range 53-83). All patients had high grade serous histology and were BRCA negative. In total, 56.5% were stage IV, 43.5% were stage III, 87.0% had a partial response, while 13.0% had stable disease by RECIST 1.1. Median peritoneal cancer index was 24 (range 6-38). Following MIRRORS protocol, 87.0% (20/23) underwent robotic interval debulking surgery, and 13.0% (3/23) had open surgery. All patients achieved R<1 (robotic R0=47.4%, open R0=0%). No patients had conversion to open. Median estimated blood loss was 50 mL for robotic (range 20-500 mL), 2026 mL for open (range 2000-2800 mL) (p=0.001). Median intensive care length of stay was 0 days for robotic (range 0-8) and 3 days (range 3-13) for MIRRORS Open (p=0.012). The median length of stay was 1.5 days for robotic (range 1-17), 6 days for open (range 5-41) (p=0.012). The time to chemotherapy was as follows 18.5 days for robotic (range 13-28), 25 days for open (range 22-28) (p=0.139). CONCLUSIONS Robotic interval debulking surgery appears safe and feasible for experienced robotic surgeons in patients with a pelvic mass ≤8 cm. A randomized controlled trial (MIRRORS-RCT) will determine whether MIRRORS protocol has non-inferior survival (overall and progression-free) compared with open interval debulking surgery.
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Affiliation(s)
- Christina Uwins
- Academic Department of Gynaecological Oncology, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
- School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Hasanthi Assalaarachchi
- Academic Department of Gynaecological Oncology, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Kate Bennett
- Surrey Clinical Trials Unit, University of Surrey, Guildford, Surrey, UK
| | - James Read
- Department of General Surgery, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Anil Tailor
- Academic Department of Gynaecological Oncology, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - James Crawshaw
- Department or Radiology, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Jayanta Chatterjee
- Academic Department of Gynaecological Oncology, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Patricia Ellis
- Academic Department of Gynaecological Oncology, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, Surrey, UK
| | - Agnieszka Michael
- School of Biosciences and Medicine, University of Surrey, Guildford, UK
- Surrey Clinical Trials Unit, University of Surrey, Guildford, Surrey, UK
- St Luke's Cancer Centre, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Simon Butler-Manuel
- Academic Department of Gynaecological Oncology, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
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Jones CJ, Read R, O'Donnell N, Wakelin K, John M, Skene SS, Stewart R, Hale L, Cooke D, Kanumakala S, Satherley RM. PRIORITY Trial: Results from a feasibility randomised controlled trial of a psychoeducational intervention for parents to prevent disordered eating in children and young people with type 1 diabetes. Diabet Med 2024; 41:e15263. [PMID: 38100228 DOI: 10.1111/dme.15263] [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: 08/18/2023] [Revised: 11/15/2023] [Accepted: 11/20/2023] [Indexed: 03/16/2024]
Abstract
AIMS Children and young people (CYP) with type 1 diabetes (T1D) are at increased risk of disordered eating. This study aimed to determine the feasibility and acceptability of a novel, theoretically informed, two-session psychoeducational intervention for parents to prevent disordered eating in CYP with T1D. METHODS Parents of CYP aged 11-14 years with T1D were randomly allocated to the intervention or wait-list control group. Self-reported measures including the Diabetes Eating Problem Survey-Revised (DEPS-R), Problem Areas in Diabetes Parent Revised (PAID-PR), Child Eating Behaviour Questionnaire subscales (CEBQ), Warwick Edinburgh Mental Wellbeing Scale (WEMWBS), clinical outcomes (e.g. HbA1c, BMI, medication and healthcare utilisation) and process variables, were collected at baseline, 1-and 3-month assessments. Acceptability data were collected from intervention participants via questionnaire. RESULTS Eighty-nine parents were recruited, which exceeded recruitment targets, with high intervention engagement and acceptability (<80% across domains). A signal of efficacy was observed across outcome measures with moderate improvements in the CEBQ subscale satiety responsiveness (d = 0.55, 95% CI 0.01, 1.08) and child's BMI (d = -0.56, 95% CI -1.09, 0.00) at 3 months compared with controls. Trends in the anticipated direction were also observed with reductions in disordered eating (DEPS-R) and diabetes distress (PAID-PR) and improvements in wellbeing (WEMWBS). CONCLUSIONS This is the first study to have co-designed and evaluated a novel parenting intervention to prevent disordered eating in CYP with T1D. The intervention proved feasible and acceptable with encouraging effects. Preparatory work is required prior to definitive trial to ensure the most relevant primary outcome measure and ensure strategies for optimum outcome completion.
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Affiliation(s)
- Christina J Jones
- School of Psychology, Faculty of Health and Medical Science, University of Surrey, Guildford, UK
| | - Rebecca Read
- School of Psychology, Faculty of Health and Medical Science, University of Surrey, Guildford, UK
| | - Nicola O'Donnell
- School of Psychology, Faculty of Health and Medical Science, University of Surrey, Guildford, UK
| | - Katherine Wakelin
- School of Psychology, Faculty of Health and Medical Science, University of Surrey, Guildford, UK
| | - Mary John
- School of Psychology, Faculty of Health and Medical Science, University of Surrey, Guildford, UK
- Sussex Partnership NHS Foundation Trust, Research and Development Department, Sussex Education Centre, Hove, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Rose Stewart
- Betsi Cadwaladr University Health Board, Wrexham, UK
| | - Lucy Hale
- School of Psychology, Faculty of Health and Medical Science, University of Surrey, Guildford, UK
| | - Debbie Cooke
- School of Health Sciences, University of Surrey, Guildford, UK
| | - Shankar Kanumakala
- Royal Alexandra Children's Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Rose-Marie Satherley
- School of Psychology, Faculty of Health and Medical Science, University of Surrey, Guildford, UK
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Goldberg AJ, Bordea E, Chowdhury K, Hauptmannova I, Blackstone J, Brooking D, Deane EL, Bendall S, Bing A, Blundell C, Dhar S, Molloy A, Milner S, Karski M, Hepple S, Siddique M, Loveday DT, Mishra V, Cooke P, Halliwell P, Townshend D, Skene SS, Doré CJ. Cost-Utility Analysis of Total Ankle Replacement Compared with Ankle Arthrodesis for Patients Aged 50-85 Years with End-Stage Ankle Osteoarthritis: The TARVA Study. Pharmacoecon Open 2024; 8:235-249. [PMID: 38189868 PMCID: PMC10884388 DOI: 10.1007/s41669-023-00449-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Patients with end-stage ankle osteoarthritis suffer from reduced mobility and quality of life and the main surgical treatments are total ankle replacement (TAR) and ankle fusion (AF). OBJECTIVES Our aim was to calculate the mean incremental cost per quality-adjusted life-year (QALY) of TAR compared with AF in patients with end-stage ankle osteoarthritis, over 52 weeks and over the patients' lifetime. METHOD We conducted a cost-utility analysis of 282 participants from 17 UK centres recruited to a randomised controlled trial (TARVA). QALYs were calculated using index values from EQ-5D-5L. Resource use information was collected from case report forms and self-completed questionnaires. Primary analysis was within-trial analysis from the National Health Service (NHS) and Personal Social Services (PSS) perspective, while secondary analyses were within-trial analysis from wider perspective and long-term economic modelling. Adjustments were made for baseline resource use and index values. RESULTS Total cost at 52 weeks was higher in the TAR group compared with the AF group, from the NHS and PSS perspective (mean adjusted difference £2539, 95% confidence interval [CI] £1142, £3897). The difference became very small from the wider perspective (£155, 95% CI - £1947, £2331). There was no significant difference between TAR and AF in terms of QALYs (mean adjusted difference 0.02, 95% CI - 0.015, 0.05) at 52 weeks post-operation. The incremental cost-effectiveness ratio (ICER) was £131,999 per QALY gained 52 weeks post-operation. Long-term economic modelling resulted in an ICER of £4200 per QALY gained, and there is a 69% probability of TAR being cost effective at a cost-effectiveness threshold of £20,000 per QALY gained. CONCLUSION TAR does not appear to be cost effective over AF 52 weeks post-operation. A decision model suggests that TAR can be cost effective over the patients' lifetime but there is a need for longer-term prospectively collected data. Clinical trial registration ISRCTN60672307 and ClinicalTrials.gov NCT02128555.
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Affiliation(s)
- Andrew J Goldberg
- Division of Surgery, UCL Institute of Orthopaedics and Musculoskeletal Science, Royal Free Hospital, 9th Floor (East), 2QG, 10 Pond St, London, NW3 2PS, UK
- Department of Research and Innovation, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, Middlesex, UK
- MSK Lab, Imperial College London, Sir Michael Uren Hub Imperial College London White City Campus, 86 Wood Lane, London, W12 0BZ, UK
| | - Ekaterina Bordea
- UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, London, WC1V 6LJ, UK.
| | - Kashfia Chowdhury
- UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, London, WC1V 6LJ, UK
| | - Iva Hauptmannova
- Department of Research and Innovation, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, Middlesex, UK
| | - James Blackstone
- UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, London, WC1V 6LJ, UK
| | - Deirdre Brooking
- Department of Research and Innovation, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, Middlesex, UK
| | - Elizabeth L Deane
- UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, London, WC1V 6LJ, UK
| | - Stephen Bendall
- University Hospitals Sussex NHS Foundation Trust, Lewes Road, Haywards Heath, RH16 4EX, UK
| | - Andrew Bing
- The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, SY10 7AG, Shropshire, UK
| | - Chris Blundell
- Sheffield Teaching Hospitals NHS Trust, Northern General Hospital, Sheffield, S5 7AU, UK
| | - Sunil Dhar
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Andrew Molloy
- Liverpool University Hospitals NHS Foundation Trust, Fazakerley, L9 7AL, Liverpool, UK
| | - Steve Milner
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE, UK
| | - Mike Karski
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, WN6 9EP, Lancashire, UK
| | - Steve Hepple
- North Bristol NHS Trust, Southmead Rd, Bristol, BS10 5NB, UK
| | - Malik Siddique
- Newcastle Hospitals NHS Foundation Trust, Freeman Hospital, Freeman Road, Newcastle upon Tyne, NE7 7DN, UK
| | - David T Loveday
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk and Norwich University Hospital Colney Lane, Norwich, NR4 7UY, UK
| | - Viren Mishra
- Hull University Teaching Hospitals NHS Trust, Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ, UK
| | - Paul Cooke
- Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, UK
| | - Paul Halliwell
- Royal Surrey NHS Foundation Trust, Guildford, GU2 7XX, Surrey, UK
| | - David Townshend
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, North Shields, NE29 8NH, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, Surrey, UK
| | - Caroline J Doré
- UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, London, WC1V 6LJ, UK
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Rodway AD, Hanna L, Harris J, Jarrett R, Allan C, Pazos Casal F, Field BC, Whyte MB, Ntagiantas N, Walton I, Pankhania A, Skene SS, Maytham GD, Heiss C. Prognostic and predictive value of ultrasound-based estimated ankle brachial pressure index at early follow-up after endovascular revascularization of chronic limb-threatening ischaemia: a prospective, single-centre, service evaluation. EClinicalMedicine 2024; 68:102410. [PMID: 38273891 PMCID: PMC10809069 DOI: 10.1016/j.eclinm.2023.102410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
Background Ankle brachial pressure index can be estimated (eABPI) using cuffless ankle Doppler ultrasound. We evaluated the prognostic value of eABPI measured during pre- and post-procedural ultrasound exams to predict the clinical outcome after endovascular revascularisations. Methods In this prospective, single-centre, service evaluation, consecutive patients with symptomatic peripheral artery disease undergoing lower limb endovascular revascularisations between July, 26 2018 and January, 13 2022 at Surrey and Sussex Healthcare NHS Trust (Redhill, UK) were analysed. eABPI was determined using the higher acceleration index measured with angle-corrected duplex ultrasound in ankle arteries before and ≤1 month post-procedure. Clinical outcomes (mortality, major amputations, amputation-free survival [AFS], clinically driven target lesion revascularization [cdTLR], major adverse limb events [MALE; cdTLR and major amputation], wound healing) were assessed over 1 year. Findings Of 246 patients treated, for 219 patients (median 75 [IQR 66-83] years) pre- and post-procedural eABPI (0.50 [0.33-0.59] and 0.90 [0.69-1.0], p < 0.0001) were available, respectively. In n = 199 patients with chronic limb-threatening ischaemia (CLTI) Kaplan-Meier survival analyses showed that higher post-procedural, but not pre-procedural, eABPI was associated with favourable AFS, MALE, cdTLR, and wound healing. This was confirmed in Cox regression analysis and remained significant with adjustment for pre-procedural eABPI, age, sex, co-morbidities, treated levels, wound score, and foot infection. Whereas all clinical outcomes, except for survival, were significantly better at ≥0.7 vs <0.7, wound healing (unadjusted: HR 1.7 (95% CI 1.2-2.6), adjusted: HR 2.1 (95% CI 1.3-3.1), cdTLR, and MALE (unadjusted: HR 0.41 (95% CI 0.18-0.93), adjusted: HR 0.28 (95% CI 0.11-0.74) were significantly improved at ≥0.9 vs <0.9. Interpretation Post-procedural eABPI can provide valid, clinically important prognostic and predictive information. Our data indicate that revascularisations should target values of at least 0.9 to achieve optimal outcomes. Future studies need to confirm generalisability and cost-effectiveness in a wider context. Funding European Partnership on Metrology, co-financed from European Union's Horizon Europe Research and Innovation Programme and UK Research and Innovation.
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Affiliation(s)
- Alexander D. Rodway
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Jenny Harris
- School of Health Sciences, University of Surrey, Guildford, UK
| | - Rachael Jarrett
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - Charlotte Allan
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - Felipe Pazos Casal
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - Benjamin C.T. Field
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Martin B. Whyte
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Nikolaos Ntagiantas
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
- St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Ivan Walton
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
- St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Ajay Pankhania
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - Simon S. Skene
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Gary D. Maytham
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
- St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Christian Heiss
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
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Taylor C, Ollis L, Lyon RM, Williams J, Skene SS, Bennett K, Glover M, Munro S, Mortimer C. The SEE-IT Trial: emergency medical services Streaming Enabled Evaluation In Trauma: a feasibility randomised controlled trial. Scand J Trauma Resusc Emerg Med 2024; 32:7. [PMID: 38383402 PMCID: PMC10883301 DOI: 10.1186/s13049-024-01179-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/10/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Use of bystander video livestreaming from scene to Emergency Medical Services (EMS) is becoming increasingly common to aid decision making about the resources required. Possible benefits include earlier, more appropriate dispatch and clinical and financial gains, but evidence is sparse. METHODS A feasibility randomised controlled trial with an embedded process evaluation and exploratory economic evaluation where working shifts during six trial weeks were randomised 1:1 to use video livestreaming during eligible trauma incidents (using GoodSAM Instant-On-Scene) or standard care only. Pre-defined progression criteria were: (1) ≥ 70% callers (bystanders) with smartphones agreeing and able to activate live stream; (2) ≥ 50% requests to activate resulting in footage being viewed; (3) Helicopter Emergency Medical Services (HEMS) stand-down rate reducing by ≥ 10% as a result of live footage; (4) no evidence of psychological harm in callers or staff/dispatchers. Observational sub-studies included (i) an inner-city EMS who routinely use video livestreaming to explore acceptability in a diverse population; and (ii) staff wellbeing in an EMS not using video livestreaming for comparison to the trial site. RESULTS Sixty-two shifts were randomised, including 240 incidents (132 control; 108 intervention). Livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to determine appropriateness of dispatch), and caller recruitment (to measure potential harm) were low (58/269, 22% of patients; 4/244, 2% of callers). Two progression criteria were met: (1) 86% of callers with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in footage being obtained; and two were indeterminate due to insufficient data: (3) 2/6 (33%) HEMS stand down due to livestreaming; (4) no evidence of psychological harm from survey, observations or interviews, but insufficient survey data from callers or comparison EMS site to be confident. Language barriers and older age were reported in interviews as potential challenges to video livestreaming by dispatchers in the inner-city EMS. CONCLUSIONS Progression to a definitive RCT is supported by these findings. Bystander video livestreaming from scene is feasible to implement, acceptable to both 999 callers and dispatchers, and may aid dispatch decision-making. Further assessment of unintended consequences, benefits and harm is required. TRIAL REGISTRATION ISRCTN 11449333 (22 March 2022). https://www.isrctn.com/ISRCTN11449333.
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Affiliation(s)
- Cath Taylor
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK.
| | - Lucie Ollis
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK
| | - Richard M Lyon
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK
- Kent, Surrey and Sussex Air Ambulance, Redhill, UK
| | - Julia Williams
- South East Coast Ambulance Service NHS Foundation Trust, Crawley, West Sussex, UK
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
| | - Kate Bennett
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
| | - Matthew Glover
- Surrey Health Economics Centre, School of Biosciences, University of Surrey, Guildford, UK
| | - Scott Munro
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK
| | - Craig Mortimer
- South East Coast Ambulance Service NHS Foundation Trust, Crawley, West Sussex, UK
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Harrop E, Liossi C, Jamieson L, Gastine S, Oulton K, Skene SS, Howard RF, Johnson M, Boyce K, Mitchell L, Jassal S, Anderson AK, Hain RDW, Hills M, Bayliss J, Soman A, Laddie J, Vickers D, Mellor C, Warlow T, Wong IC. Oral morphine versus transmucosal diamorphine for breakthrough pain in children: methods and outcomes: UK (DIPPER study) consensus. BMJ Support Palliat Care 2024; 13:e1019-e1028. [PMID: 34903585 PMCID: PMC10850727 DOI: 10.1136/bmjspcare-2021-003278] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/04/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES No randomised controlled trials have been conducted for breakthrough pain in paediatric palliative care and there are currently no standardised outcome measures. The DIPPER study aims to establish the feasibility of conducting a prospective randomised controlled trial comparing oral and transmucosal administration of opioids for breakthrough pain. The aim of the current study was to achieve consensus on design aspects for a small-scale prospective study to inform a future randomised controlled trial of oral morphine, the current first-line treatment, versus transmucosal diamorphine. METHODS The nominal group technique was used to achieve consensus on best practice for mode of administration, dose regimen and a range of suitable pain intensity outcome measures for transmucosal diamorphine in children and young people with breakthrough pain. An expert panel of ten clinicians in paediatric palliative care and three parent representatives participated. Consensus was achieved when agreement was reached and no further comments from participants were forthcoming. RESULTS The panel favoured the buccal route of administration, with dosing according to the recommendations in the Association for Paediatric Palliative Medicine formulary (fifth Edition, 2020). The verbal Numerical Rating Scale was selected to measure pain in children 8 years old and older, the Faces Pain Scale-Revised for children between 4 and 8 years old, and Face, Legs, Activity, Cry and Consolability (FLACC)/FLACC-Revised as the observational tools. CONCLUSIONS The nominal group technique allowed consensus to be reached for a small-scale, prospective, cohort study and provided information to inform the design of a randomised controlled trial.
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Affiliation(s)
- Emily Harrop
- Helen and Douglas House Hospice, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Christina Liossi
- School of Psychology, University of Southampton, Southampton, UK
- Department of Psychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Liz Jamieson
- Research Dept of Practice & Policy, University College London School of Pharmacy, London, UK
- UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
| | - Silke Gastine
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Kate Oulton
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
- School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Margaret Johnson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Katherine Boyce
- Helen and Douglas House Hospice, Oxford, UK
- Flexicare Oxford & Abingdon, Oxford, UK
| | | | - Satbir Jassal
- Rainbows Hospice for Children and Young People, Loughborough, UK
| | - Anna-Karenia Anderson
- Paediatrics, Royal Marsden Hospital, Sutton, UK
- Shooting Star Children's Hospice, Guildford, UK
| | - Richard D W Hain
- All-Wales Managed Clinical Network in Paediatric Palliative Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Michelle Hills
- Martin House Hospice for Children and Young People, Boston Spa, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Julie Bayliss
- The Louis Dundas Centre, Oncology Outreach and Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Archana Soman
- Sheffield Children's Hospital, Sheffield, UK
- Bluebell Wood Children's Hospice, North Anston, UK
| | | | - David Vickers
- Medical Director, Cambridgeshire Community Services NHS Trust, St Ives, UK
- East Anglia's Children's Hospices, Cambridgeshire, UK
| | | | - Tim Warlow
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Naomi House and Jacksplace, Winchester, UK
| | - Ian Ck Wong
- Research Dept of Practice & Policy, University College London School of Pharmacy, London, UK
- UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Pok Fu Lam, Hong Kong
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Barrett JW, Williams J, Skene SS, Griggs JE, Bootland D, Leung J, Da Costa A, Ballantyne K, Davies R, Lyon RM. Head injury in older adults presenting to the ambulance service: who do we convey to the emergency department, and what clinical variables are associated with an intracranial bleed? A retrospective case-control study. Scand J Trauma Resusc Emerg Med 2023; 31:65. [PMID: 37908011 PMCID: PMC10619243 DOI: 10.1186/s13049-023-01138-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE Most older adults with traumatic brain injuries (TBI) reach the emergency department via the ambulance service. Older adults, often with mild TBI symptoms, risk being under-triaged and facing poor outcomes. This study aimed to identify whether sufficient information is available on the scene to an ambulance clinician to identify an older adult at risk of an intracranial haemorrhage following a head injury. METHODS This was a retrospective case-control observational study involving one regional ambulance service in the UK and eight emergency departments. 3545 patients aged 60 years and over presented to one regional ambulance service with a head injury between the 1st of January 2020 and the 31st of December 2020. The primary outcome was an acute intracranial haemorrhage on head computed tomography (CT) scan in patients conveyed to the emergency department (ED). A secondary outcome was factors associated with conveyance to the ED by the ambulance clinician. RESULTS In 2020, 2111 patients were conveyed to the ED and 162 patients were found to have an intracranial haemorrhage on their head CT scan. Falls from more than 2 m (adjusted odds ratio (aOR) 3.45, 95% CI 1.78-6.40), chronic kidney disease (CKD) (aOR 2.80, 95% CI 1.25-5.75) and Clopidogrel (aOR 1.98, 95% CI 1.04-3.59) were associated with an intracranial haemorrhage. Conveyance to the ED was associated with patients taking anticoagulant and antiplatelet medication or a visible head injury or head injury symptoms. CONCLUSION This study highlights that while most older adults with a head injury are conveyed to the ED, only a minority will have an intracranial haemorrhage following their head injury. While mechanisms of injury such as falls from more than 2 m remain a predictor, this work highlights that Clopidogrel and CKD are also associated with an increased odds of tICH in older adults following a head injury. These findings may warrant a review of current ambulance head injury guidelines.
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Affiliation(s)
- J W Barrett
- South East Coast Ambulance Service NHS FT, Crawley, UK.
- University of Surrey, Guildford, UK.
| | - J Williams
- South East Coast Ambulance Service NHS FT, Crawley, UK
- Paramedic Clinical Research Unit, University of Hatfield, Hatfield, UK
| | | | - J E Griggs
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
| | - D Bootland
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - J Leung
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - A Da Costa
- Medway Maritime Hospital NHS FT, Gillingham, UK
| | - K Ballantyne
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - R Davies
- South East Coast Ambulance Service NHS FT, Crawley, UK
| | - R M Lyon
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
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8
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Rodway AD, Harris J, Hanna L, Allan C, Casal FP, Giltinan C, Dehghan-Nayeri A, Santos A, Whyte MB, Ntagiantas N, Walton I, Brown R, Skene SS, Pankhania A, Field BCT, Maytham GD, Heiss C. Understanding the Impact of COVID-19 on Angioplasty Service and Outcome of Patients Treated for Chronic Limb-Threatening Ischaemia: A Single-Centre Retrospective Cohort Study. Biomedicines 2023; 11:2034. [PMID: 37509673 PMCID: PMC10377405 DOI: 10.3390/biomedicines11072034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/09/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
We evaluated the impact of COVID-19 restriction on the angioplasty service and outcome of chronic limb-threatening ischaemia (CLTI) patients undergoing lower-limb angioplasty in a UK secondary care setting. Consecutive patients were analysed retrospectively. Pre-COVID-19 (08/2018-02/2020), 106 CLTI patients (91% Fontaine 4; 60% diabetes mellitus) and during COVID-19 (03/2020-07/2021) 94 patients were treated (86% Fontaine 4; 66% diabetes mellitus). While the average monthly number of patients treated did not change, the proportion of day cases significantly increased (53% to 80%), and hospitalised patients decreased. Patients treated in ≤14/5 days after referral significantly increased to 64/63%. Kaplan-Meier survival analysis (30-day/1-year) showed that neither wound healing nor mortality were significantly changed during COVID-19. In day cases, 1-year but not 30-day major amputations significantly increased, and clinically driven target-lesion revascularisation decreased during COVID-19. One-year mortality was significantly worse in hospitalised compared to day cases (14% vs. 43%) at similar wound healing rates (83% vs. 84%). The most frequent known cause of death was infectious disease (64%), while cardiovascular (21%) was less frequent. Despite COVID-19 restrictions, a safe and effective angioplasty service was maintained while shortening waiting times. Very high mortality rates in hospitalised patients may indicate that CLTI patients need to be referred and treated more aggressively earlier.
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Affiliation(s)
- Alexander D Rodway
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Vascular Surgery, University Hospital Sussex NHS Trust, Brighton BN2 5BE, UK
| | - Jenny Harris
- Department of Adult Nursing, School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Lydia Hanna
- Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London SW7 2BX, UK
| | - Charlotte Allan
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Felipe Pazos Casal
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Ciara Giltinan
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Ali Dehghan-Nayeri
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Andre Santos
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Martin B Whyte
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Nikolaos Ntagiantas
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- St. George's Vascular Institute, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Ivan Walton
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- St. George's Vascular Institute, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Richard Brown
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Simon S Skene
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Ajay Pankhania
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Benjamin C T Field
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Gary D Maytham
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- St. George's Vascular Institute, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Christian Heiss
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
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Ollis L, Skene SS, Williams J, Lyon R, Taylor C. The SEE-IT Trial: emergency medical services Streaming Enabled Evaluation In Trauma: study protocol for an interventional feasibility randomised controlled trial. BMJ Open 2023; 13:e072877. [PMID: 37094896 PMCID: PMC10151834 DOI: 10.1136/bmjopen-2023-072877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
INTRODUCTION Accurate and timely dispatch of emergency medical services (EMS) is vital due to limited resources and patients' risk of mortality and morbidity increasing with time. Currently, most UK emergency operations centres (EOCs) rely on audio calls and accurate descriptions of the incident and patients' injuries from lay 999 callers. If dispatchers in the EOCs could see the scene via live video streaming from the caller's smartphone, this may enhance their decision making and enable quicker and more accurate dispatch of EMS. The main aim of this feasibility randomised controlled trial (RCT) is to assess the feasibility of conducting a definitive RCT to assess the clinical and cost effectiveness of using live streaming to improve targeting of EMS. METHODS AND ANALYSIS The SEE-IT Trial is a feasibility RCT with a nested process evaluation. The study also has two observational substudies: (1) in an EOC that routinely uses live streaming to assess the acceptability and feasibility of live streaming in a diverse inner-city population and (2) in an EOC that does not currently use live streaming to act as a comparator site regarding the psychological well-being of EOC staff using versus not using live streaming. ETHICS AND DISSEMINATION The study was approved by the Health Research Authority on 23 March 2022 (ref: 21/LO/0912), which included NHS Confidentiality Advisory Group approval received on 22 March 2022 (ref: 22/CAG/0003). This manuscript refers to V.0.8 of the protocol (7 November 2022). The trial is registered with the ISRCTN (ISRCTN11449333). The first participant was recruited on 18 June 2022.The main output of this feasibility trial will be the knowledge gained to help inform the development of a large multicentre RCT to evaluate the clinical and cost effectiveness of the use of live streaming to aid EMS dispatch for trauma incidents. TRIAL REGISTRATION NUMBER ISRCTN11449333.
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Affiliation(s)
- Lucie Ollis
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
| | - Julia Williams
- South East Coast Ambulance Service NHS Foundation Trust, Banstead, Surrey, UK
- University of Hertfordshire School of Health and Social Work, Hatfield, UK
| | - Richard Lyon
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK
- Kent, Surrey & Sussex Air Ambulance, Redhill, UK
| | - Cath Taylor
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK
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10
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Heiss C, Rodriguez-Mateos A, Bapir M, Skene SS, Sies H, Kelm M. Flow-mediated dilation reference values for evaluation of endothelial function and cardiovascular health. Cardiovasc Res 2023; 119:283-293. [PMID: 35709326 DOI: 10.1093/cvr/cvac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 05/19/2022] [Accepted: 05/25/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Endothelial function is essential for cardiovascular health, and flow-mediated dilation (FMD) is an established technique to measure it. This paper aims to assess FMD values in apparently healthy individuals and provides reference values to facilitate wider clinical use. METHODS AND RESULTS In 1,579 apparently healthy individuals (aged 18-76), fasted FMD values (data from 44 studies, 6 institutions, 22 operators) were normally distributed and inversely univariately correlated with age, body mass index, glucose, cholesterol, blood pressure, and brachial artery (BA) diameter. Significant multivariate predictors of FMD were age (-0.4%/decade), BMI (0.04%/kg/m2), smoking (-0.7%), and BA diameter (-0.44%/mm) that together explained 19% of the variability independent of operator, institution or ultrasound machine. Individuals in the high FMD tertile (>6.8%) were younger, had smaller BA diameter, lower blood pressure and cholesterol. In individuals with low- and intermediate fatal cardiovascular risk (SCORE), 26% and 53% of individuals, respectively, had FMD values in the low tertile (<5.4%). After adding data from 385 patients with stable coronary artery disease (CAD), ROC analysis (c = 0.841, P < 0.001) showed that FMD of >6.5% excluded CAD (95% sensitivity; 60% specificity) and FMD <3.1% excluded 95% healthy individuals (95% specificity, 31% sensitivity). A meta-analysis and meta-regression of 82 clinical trials (11 countries, n = 3,509) using similar FMD methodology showed that despite considerable heterogeneity (I2 = 0.97) FMD in healthy individuals was on average 6.4% (95%CI: 6.2%, 6.7%) with no significant differences between countries but a significant age-dependent decline (-0.3%/decade, R2 = 0.13). CONCLUSIONS We provide an age-adapted frame of FMD reference intervals in apparently healthy individuals for use as a biomarker of cardiovascular health. As the degree of vascular endothelial function integrates environmental and genetic factors with classical CV risk factors, FMD may more comprehensively classify individuals with and without standard modifiable cardiovascular risk factors and serve as a target for cardiovascular prevention.
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Affiliation(s)
- Christian Heiss
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Stag Hill, Guildford GU2 7XH, UK
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Vascular Department, Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Redhill, UK
| | - Ana Rodriguez-Mateos
- Department of Nutritional Sciences, School of Life Course and Population Sciences, King's College London, London, UK
| | - Mariam Bapir
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Stag Hill, Guildford GU2 7XH, UK
| | - Simon S Skene
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Stag Hill, Guildford GU2 7XH, UK
| | - Helmut Sies
- Institute for Molecular Biology and Biochemistry I, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Leibniz Research Institute for Environmental Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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11
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Goldberg AJ, Chowdhury K, Bordea E, Blackstone J, Brooking D, Deane EL, Hauptmannova I, Cooke P, Cumbers M, Skene SS, Doré CJ. Total ankle replacement versus ankle arthrodesis for patients aged 50-85 years with end-stage ankle osteoarthritis: the TARVA RCT. Health Technol Assess 2023; 27:1-80. [PMID: 37022932 PMCID: PMC10150410 DOI: 10.3310/ptyj1146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Background We aimed to compare the clinical effectiveness, cost-effectiveness and complication rates of total ankle replacement with those of arthrodesis (i.e. ankle fusion) in the treatment of end-stage ankle osteoarthritis. Methods This was a pragmatic, multicentre, parallel-group, non-blinded randomised controlled trial. Patients with end-stage ankle osteoarthritis who were aged 50-85 years and were suitable for both procedures were recruited from 17 UK hospitals and randomised using minimisation. The primary outcome was the change in the Manchester-Oxford Foot Questionnaire walking/standing domain scores between the preoperative baseline and 52 weeks post surgery. Results Between March 2015 and January 2019, 303 participants were randomised using a minimisation algorithm: 152 to total ankle replacement and 151 to ankle fusion. At 52 weeks, the mean (standard deviation) Manchester-Oxford Foot Questionnaire walking/standing domain score was 31.4 (30.4) in the total ankle replacement arm (n = 136) and 36.8 (30.6) in the ankle fusion arm (n = 140); the adjusted difference in the change was -5.6 (95% confidence interval -12.5 to 1.4; p = 0.12) in the intention-to-treat analysis. By week 52, one patient in the total ankle replacement arm required revision. Rates of wound-healing issues (13.4% vs. 5.7%) and nerve injuries (4.2% vs. < 1%) were higher and the rate of thromboembolic events was lower (2.9% vs. 4.9%) in the total ankle replacement arm than in the ankle fusion arm. The bone non-union rate (based on plain radiographs) in the ankle fusion arm was 12.1%, but only 7.1% of patients had symptoms. A post hoc analysis of fixed-bearing total ankle replacement showed a statistically significant improvement over ankle fusion in Manchester-Oxford Foot Questionnaire walking/standing domain score (-11.1, 95% confidence interval -19.3 to -2.9; p = 0.008). We estimate a 69% likelihood that total ankle replacement is cost-effective compared with ankle fusion at the National Institute for Health and Care Excellence's cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained over the patient's lifetime. Limitations This initial report contains only 52-week data, which must therefore be interpreted with caution. In addition, the pragmatic nature of the study means that there was heterogeneity between surgical implants and techniques. The trial was run across 17 NHS centres to ensure that decision-making streams reflected the standard of care in the NHS as closely as possible. Conclusions Both total ankle replacement and ankle fusion improved patients' quality of life at 1 year, and both appear to be safe. When total ankle replacement was compared with ankle fusion overall, we were unable to show a statistically significant difference between the two arms in terms of our primary outcome measure. The total ankle replacement versus ankle arthrodesis (TARVA) trial is inconclusive in terms of superiority of total ankle replacement, as the 95% confidence interval for the adjusted treatment effect includes both a difference of zero and the minimal important difference of 12, but it can rule out the superiority of ankle fusion. A post hoc analysis comparing fixed-bearing total ankle replacement with ankle fusion showed a statistically significant improvement of total ankle replacement over ankle fusion in Manchester-Oxford Foot Questionnaire walking/standing domain score. Total ankle replacement appears to be cost-effective compared with ankle fusion at the National Institute for Health and Care Excellence's cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained over a patient's lifetime based on long-term economic modelling. Future work We recommend long-term follow-up of this important cohort, in particular radiological and clinical progress. We also recommend studies to explore the sensitivity of clinical scores to detect clinically important differences between arms when both have already achieved a significant improvement from baseline. Trial registration This trial is registered as ISRCTN60672307 and ClinicalTrials.gov NCT02128555. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Andrew J Goldberg
- Institute of Orthopaedics & Musculoskeletal Science, Division of Surgery, University College London, London, UK
| | - Kashfia Chowdhury
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Ekaterina Bordea
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - James Blackstone
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Deirdre Brooking
- Department of Research & Innovation, Royal National Orthopaedic Hospital, London, UK
| | - Elizabeth L Deane
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Iva Hauptmannova
- Department of Research & Innovation, Royal National Orthopaedic Hospital, London, UK
| | - Paul Cooke
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Marion Cumbers
- Department of Research & Innovation, Royal National Orthopaedic Hospital, London, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
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12
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Barley EA, Bovell M, Bennett-Eastley K, Lee JT, Lee-Baggley D, Skene SS, Tai MZ, Brooks S, Scholtz S. Addressing a critical need: A randomised controlled feasibility trial of acceptance and commitment therapy for bariatric surgery patients at 15-18 months post-surgery. PLoS One 2023; 18:e0282849. [PMID: 37098049 PMCID: PMC10128967 DOI: 10.1371/journal.pone.0282849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 02/17/2023] [Indexed: 04/26/2023] Open
Abstract
Bariatric surgery is an effective treatment for obesity. However, around one in five people experience significant weight regain. Acceptance and Commitment Therapy (ACT) teaches acceptance of and defusion from thoughts and feelings which influence behaviour, and commitment to act in line with personal values. To test the feasibility and acceptability of ACT following bariatric surgery a randomised controlled trial of 10 sessions of group ACT or Usual Care Support Group control (SGC) was delivered 15-18 months post bariatric surgery (ISRCTN registry ID: ISRCTN52074801). Participants were compared at baseline, 3, 6 and 12 months using validated questionnaires to assess weight, wellbeing, and healthcare use. A nested, semi-structured interview study was conducted to understand acceptability of the trial and group processes. 80 participants were consented and randomised. Attendance was low for both groups. Only 9 (29%) ACT participants completed > = half of the sessions, this was the case for 13 (35%) SGC participants. Forty-six (57.5%) did not attend the first session. At 12 months, outcome data were available from 19 of the 38 receiving SGC, and from 13 of the 42 receiving ACT. Full datasets were collected for those who remained in the trial. Nine participants from each arm were interviewed. The main barriers to group attendance were travel difficulties and scheduling. Poor initial attendance led to reduced motivation to return. Participants reported a motivation to help others as a reason to join the trial; lack of attendance by peers removed this opportunity and led to further drop out. Participants who attended the ACT groups reported a range of benefits including behaviour change. We conclude that the trial processes were feasible, but that the ACT intervention was not acceptable as delivered. Our data suggest changes to recruitment and intervention delivery that would address this.
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Affiliation(s)
- Elizabeth A Barley
- School of Health Sciences, University of Surrey, Guildford, United Kingdom
| | - Marie Bovell
- School of Health Sciences, University of Surrey, Guildford, United Kingdom
| | - Kate Bennett-Eastley
- School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - John Tayu Lee
- School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia
| | | | - Simon S Skene
- School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Michael Z Tai
- Department of Psychiatry, St Charles Hospital, London, United Kingdom
| | - Sue Brooks
- School of Health Sciences, University of Surrey, Guildford, United Kingdom
| | - Samantha Scholtz
- Division of Diabetes, Endocrinology and Metabolism, Imperial College, London, United Kingdom
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13
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Bapir M, Untracht GR, Hunt JEA, McVey JH, Harris J, Skene SS, Campagnolo P, Dikaios N, Rodriguez-Mateos A, Sampson DD, Sampson DM, Heiss C. Age-Dependent Decline in Common Femoral Artery Flow-Mediated Dilation and Wall Shear Stress in Healthy Subjects. Life (Basel) 2022; 12:life12122023. [PMID: 36556388 PMCID: PMC9787166 DOI: 10.3390/life12122023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Femoral artery (FA) endothelial function is a promising biomarker of lower extremity vascular health for peripheral artery disease (PAD) prevention and treatment; however, the impact of age on FA endothelial function has not been reported in healthy adults. Therefore, we evaluated the reproducibility and acceptability of flow-mediated dilation (FMD) in the FA and brachial artery (BA) (n = 20) and performed cross-sectional FA- and BA-FMD measurements in healthy non-smokers aged 22−76 years (n = 50). FMD protocols demonstrated similar good reproducibility. Leg occlusion was deemed more uncomfortable than arm occlusion; thigh occlusion was less tolerated than forearm and calf occlusion. FA-FMD with calf occlusion was lower than BA-FMD (6.0 ± 1.1% vs 6.4 ± 1.3%, p = 0.030). Multivariate linear regression analysis indicated that age (−0.4%/decade) was a significant independent predictor of FA-FMD (R2 = 0.35, p = 0.002). The age-dependent decline in FMD did not significantly differ between FA and BA (pinteraction agexlocation = 0.388). In older participants, 40% of baseline FA wall shear stress (WSS) values were <5 dyne/cm2, which is regarded as pro-atherogenic. In conclusion, endothelial function declines similarly with age in the FA and the BA in healthy adults. The age-dependent FA enlargement results in a critical decrease in WSS that may explain part of the age-dependent predisposition for PAD.
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Affiliation(s)
- Mariam Bapir
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Gavrielle R. Untracht
- Optical + Biomedical Engineering Laboratory, School of Electrical, Electronic and Computer Engineering, The University of Western Australia, Perth 6009, Australia
- Surrey Biophotonics, Advanced Technology Institute, School of Physics and School of Biosciences and Medicine, University of Surrey, Guildford GU2 7XH, UK
| | - Julie E. A. Hunt
- School of Biosciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - John H. McVey
- Department of Biochemical Sciences, School of Biosciences, University of Surrey, Guildford GU2 7XH, UK
| | - Jenny Harris
- School of Health Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Simon S. Skene
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Paola Campagnolo
- Department of Biochemical Sciences, School of Biosciences, University of Surrey, Guildford GU2 7XH, UK
| | - Nikolaos Dikaios
- Mathematics Research Center, Academy of Athens, 11855 Athens, Greece
| | - Ana Rodriguez-Mateos
- Department of Nutritional Sciences, School of Life Course and Population Sciences, Faculty of Life Science and Medicine, King’s College London, London SE1 9NH, UK
| | - David D. Sampson
- Surrey Biophotonics, Advanced Technology Institute, School of Physics and School of Biosciences and Medicine, University of Surrey, Guildford GU2 7XH, UK
| | - Danuta M. Sampson
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
- Surrey Biophotonics, Centre for Vision, Speech and Signal Processing and School of Biosciences and Medicine, University of Surrey, Guildford GU2 7XH, UK
- Institute of Ophthalmology, University College London, London SE5 9RS, UK
| | - Christian Heiss
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
- Surrey and Sussex NHS Healthcare Trust, Redhill RH1 5RH, UK
- Correspondence:
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Goldberg AJ, Chowdhury K, Bordea E, Hauptmannova I, Blackstone J, Brooking D, Deane EL, Bendall S, Bing A, Blundell C, Dhar S, Molloy A, Milner S, Karski M, Hepple S, Siddique M, Loveday DT, Mishra V, Cooke P, Halliwell P, Townshend D, Skene SS, Doré CJ, Brown R, Butler M, Chadwick C, Clough T, Cullen N, Davies M, Davies H, Harries B, Khoo M, Makwana N, Murty A, Najefi A, O'Donnell P, Raglan M, Thomas R, Torres P, Welck M, Winson I, Zaidi R. Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial. Ann Intern Med 2022; 175:1648-1657. [PMID: 36375147 DOI: 10.7326/m22-2058] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF). OBJECTIVE To determine which treatment is superior in terms of clinical scores and adverse events. DESIGN A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307). SETTING 17 National Health Service trusts across the United Kingdom. PATIENTS Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure. INTERVENTION Patients were randomly assigned to TAR or AF surgical treatment. MEASUREMENTS The primary outcome was change in Manchester-Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible. RESULTS Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was -5.6 (95% CI, -12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (-11.1 [CI, -19.3 to -2.9]). LIMITATION Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques. CONCLUSION Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%. PRIMARY FUNDING SOURCE National Institute for Health and Care Research Heath Technology Assessment Programme.
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Affiliation(s)
- Andrew J Goldberg
- UCL Institute of Orthopaedics & Musculoskeletal Science, Division of Surgery, Royal Free Hospital, MSK Lab, Imperial College London, Sir Michael Uren Hub Imperial College London White City Campus, London, and Department of Research & Innovation, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, Middlesex, United Kingdom (A.J.G.)
| | - Kashfia Chowdhury
- UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom (K.C., E.B., J.B., E.L.D., C.J.D.)
| | - Ekaterina Bordea
- UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom (K.C., E.B., J.B., E.L.D., C.J.D.)
| | - Iva Hauptmannova
- Department of Research & Innovation, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, Middlesex, United Kingdom (I.H., D.B.)
| | - James Blackstone
- UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom (K.C., E.B., J.B., E.L.D., C.J.D.)
| | - Deirdre Brooking
- Department of Research & Innovation, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, Middlesex, United Kingdom (I.H., D.B.)
| | - Elizabeth L Deane
- UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom (K.C., E.B., J.B., E.L.D., C.J.D.)
| | - Stephen Bendall
- University Hospitals Sussex NHS Foundation Trust, Haywards Heath, United Kingdom (S.B.)
| | - Andrew Bing
- The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, Shropshire, United Kingdom (A.B.)
| | - Chris Blundell
- Sheffield Teaching Hospitals NHS Trust, Northern General Hospital, Sheffield, United Kingdom (C.B.)
| | - Sunil Dhar
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom (S.D.)
| | - Andrew Molloy
- Liverpool University Hospitals NHS Foundation Trust, Fazakerley, Liverpool, United Kingdom (A.M.)
| | - Steve Milner
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom (S.M.)
| | - Mike Karski
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, Lancashire, United Kingdom (M.K.)
| | - Steve Hepple
- North Bristol NHS Trust, Bristol, United Kingdom (S.H.)
| | - Malik Siddique
- Newcastle Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, United Kingdom (M.S.)
| | - David T Loveday
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk and Norwich University Hospital, Norwich, United Kingdom (D.T.L.)
| | - Viren Mishra
- Hull University Teaching Hospitals NHS Trust, Hull Royal Infirmary, Hull, United Kingdom (V.M.)
| | - Paul Cooke
- Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, United Kingdom (P.C.)
| | - Paul Halliwell
- Royal Surrey NHS Foundation Trust, Guildford, Surrey, United Kingdom (P.H.)
| | - David Townshend
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, North Shields, United Kingdom (D.T.)
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, Surrey, United Kingdom (S.S.S.)
| | - Caroline J Doré
- UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom (K.C., E.B., J.B., E.L.D., C.J.D.)
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Davies A, Waghorn M, Roberts M, Gage H, Skene SS. Clinically assisted hydration in patients in the last days of life ('CHELsea II' trial): a cluster randomised trial. BMJ Open 2022; 12:e068846. [PMID: 36418131 PMCID: PMC9684991 DOI: 10.1136/bmjopen-2022-068846] [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] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Provision of clinically assisted hydration (CAH) at the end of life is one of the most contentious issues in medicine. The aim of the 'CHELsea II' trial is to evaluate CAH in patients in the last days of life. The objectives are to assess the effect of CAH on delirium, audible upper airway secretions, pain and other symptoms, and overall survival, as well as the tolerability of CAH, and the health economic impact. METHODS AND ANALYSIS The study is a cluster randomised trial, involving 80 sites/clusters (mainly hospices) and 1600 patients. Sites will be randomised to an intervention, and this will become the standard of care during the trial. Intervention 'A' involves continuance of drinking (if appropriate), mouth care and usual end-of-life care. Intervention 'B' involves continuance of drinking, mouth care, usual end-of-life care and CAH, that is, parenteral fluids. The fluid may be given intravenously or subcutaneously, the type will be dextrose saline (4% dextrose, 0.18% sodium chloride) and the volume will be dependent on weight.Participants will be assessed every 4 hours by the clinical team. The primary endpoint is the proportion of participants who develop delirium determined using the Nursing Delirium Screening Scale (using a cut-off score of ≥2). A mixed-effects logistic regression will be used to assess the difference in the odds of developing delirium between the interventions. ETHICS AND DISSEMINATION Ethical committee approval has been granted by the Brighton and Sussex Research Ethics Committee (REC) (main REC for the UK: reference-IRAS 313640), and by the Scotland A REC (REC for adults with incapacity in Scotland: reference-22/SS/0053-IRAS-317637). The consent process follows the Mental Capacity Act: if the patient has capacity, then consent will be sought in the normal way; if the patient does not have capacity, then a personal/nominated consultee will be approached for advice about the patient entering the study. The consent process is slightly different in Scotland.The results of the trial will be published in general medical/palliative care journals, and presented at general medical/palliative care conferences. TRIAL REGISTRATION NUMBER ISRCTN65858561.
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Affiliation(s)
- Andrew Davies
- Trinity College Dublin, Dublin, Ireland
- University College Dublin, Dublin, Ireland
- Our Lady's Hospice & Care Services, Dublin, Ireland
- University of Surrey, Guildford, UK
| | - Melanie Waghorn
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
| | - Megan Roberts
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
| | - Heather Gage
- School of Economics, University of Surrey, Guildford, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
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16
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Bapir M, Untracht GR, Cooke D, McVey JH, Skene SS, Campagnolo P, Whyte MB, Dikaios N, Rodriguez-Mateos A, Sampson DD, Sampson DM, Heiss C. Cocoa flavanol consumption improves lower extremity endothelial function in healthy individuals and people with type 2 diabetes. Food Funct 2022; 13:10439-10448. [PMID: 36164983 DOI: 10.1039/d2fo02017c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: diabetes and age are major risk factors for the development of lower extremity peripheral artery disease (PAD). Cocoa flavanol (CF) consumption is associated with lower risk for PAD and improves brachial artery (BA) endothelial function. Objectives: to assess if femoral artery (FA) endothelial function and dermal microcirculation are impaired in individuals with type 2 diabetes mellitus (T2DM) and evaluate the acute effect of CF consumption on FA endothelial function. Methods: in a randomised, controlled, double-blind, cross-over study, 22 individuals (n = 11 healthy, n = 11 T2DM) without cardiovascular disease were recruited. Participants received either 1350 mg CF or placebo capsules on 2 separate days in random order. Endothelial function was measured as flow-mediated dilation (FMD) using ultrasound of the common FA and the BA before and 2 hours after interventions. The cutaneous microvasculature was assessed using optical coherence tomography angiography. Results: baseline FA-FMD and BA-FMD were significantly lower in T2DM (FA: 3.2 ± 1.1% [SD], BA: 4.8 ± 0.8%) compared to healthy (FA: 5.5 ± 0.7%, BA: 6.0 ± 0.8%); each p < 0.001. Whereas in healthy individuals FA-FMD did not significantly differ from BA-FMD (p = 0.144), FA-FMD was significantly lower than BA-FMD in T2DM (p = 0.003) indicating pronounced and additional endothelial dysfunction of lower limb arteries (FA-FMD/BA-FMD: 94 ± 14% [healthy] vs. 68 ± 22% [T2DM], p = 0.007). The baseline FA blood flow rate (0.42 ± 0.23 vs. 0.73 ± 0.35 l min-1, p = 0.037) and microvascular dilation in response to occlusion in hands and feet were significantly lower in T2DM subjects than in healthy ones. CF increased both FA- and BA-FMD at 2 hours, compared to placebo, in both healthy and T2DM subgroups (FA-FMD effect: 2.9 ± 1.4%, BA-FMD effect 3.0 ± 3.5%, each pintervention< 0.001). In parallel, baseline FA blood flow and microvascular diameter significantly increased in feet (3.5 ± 3.5 μm, pintervention< 0.001) but not hands. Systolic blood pressure and pulse wave velocity significantly decreased after CF in both subgroups (-7.2 ± 9.6 mmHg, pintervention = 0.004; -1.3 ± 1.3 m s-1, pintervention = 0.002). Conclusions: individuals with T2DM exhibit decreased endothelial function that is more pronounced in the femoral than in the brachial artery. CFs increase endothelial function not only in the BA but also the FA both in healthy individuals and in those with T2DM who are at increased risk of developing lower extremity PAD and foot ulcers.
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Affiliation(s)
- Mariam Bapir
- Department of Clinical and Experimental Medicine, School of Bioscience & Medicine, University of Surrey, Guildford, United Kingdom.
| | - Gavrielle R Untracht
- Optical+Biomedical Engineering Laboratory, School of Electrical, Electronic and Computer Engineering, The University of Western Australia, Perth, Australia.,Surrey Biophotonics, Advanced Technology Institute, School of Physics and School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Debbie Cooke
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - John H McVey
- Department of Biochemical Sciences, School of Bioscience & Medicine, University of Surrey, Guildford, United Kingdom
| | - Simon S Skene
- Department of Clinical and Experimental Medicine, School of Bioscience & Medicine, University of Surrey, Guildford, United Kingdom.
| | - Paola Campagnolo
- Department of Biochemical Sciences, School of Bioscience & Medicine, University of Surrey, Guildford, United Kingdom
| | - Martin B Whyte
- Department of Clinical and Experimental Medicine, School of Bioscience & Medicine, University of Surrey, Guildford, United Kingdom.
| | | | - Ana Rodriguez-Mateos
- Department of Nutritional Sciences, School of Life Course and Population Sciences, Faculty of Life Science and Medicine, King's College London, London, United Kingdom
| | - David D Sampson
- Surrey Biophotonics, Advanced Technology Institute, School of Physics and School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Danuta M Sampson
- Department of Clinical and Experimental Medicine, School of Bioscience & Medicine, University of Surrey, Guildford, United Kingdom. .,Surrey Biophotonics, Centre for Vision, Speech and Signal Processing and School of Biosciences and Medicine, The University of Surrey, Guildford, United Kingdom.,University College London, Institute of Ophthalmology, London, United Kingdom
| | - Christian Heiss
- Department of Clinical and Experimental Medicine, School of Bioscience & Medicine, University of Surrey, Guildford, United Kingdom. .,Surrey and Sussex NHS Healthcare Trust, Redhill, United Kingdom
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Bapir M, Campagnolo P, Rodriguez-Mateos A, Skene SS, Heiss C. Assessing Variability in Vascular Response to Cocoa With Personal Devices: A Series of Double-Blind Randomized Crossover n-of-1 Trials. Front Nutr 2022; 9:886597. [PMID: 35769385 PMCID: PMC9234529 DOI: 10.3389/fnut.2022.886597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/17/2022] [Indexed: 12/30/2022] Open
Abstract
Controlled clinical intervention studies have demonstrated that cocoa flavanols (CF) can decrease blood pressure and arterial stiffness in healthy humans, although a large variability in the effect size across trials has been reported. In this study, we evaluated the intra- and inter-individual variability of responses to CF in everyday life using a series of n-of-1 trials in healthy free-living individuals with normal blood pressure carrying personal devices. In total, eleven healthy young humans participated in a repeated crossover randomized controlled double-blind n-of-1 trial. On 8 consecutive days, each volunteer consumed on alternating days 6 CF capsules (862 mg CF) on 4 days and 6 matched placebo capsules (P, 0 mg CF/day) on another 4 days in one of the two randomized sequences (CF-P-CF-P-CF-P-CF-P or P-CF-P-CF-P-CF-P-CF). On each day, the capsules were taken at the same time in the morning with breakfast after baseline measurements. Each subject was provided with an upper arm blood pressure monitor and a finger clip that measures pulse wave velocity (PWV). Measurements of blood pressure, heart rate, and PWV were taken at least hourly over 12 h during the day by the participants. On the first 2 days, measurements were performed under supervision to provide training. The overall mixed model analysis showed that CF significantly decreased 12-h systolic blood pressure and PWV by −1.4 ± 0.3 mmHg and −0.11 ± 0.03 m/s, respectively. Peak effects were observed within the first 3 h (1.5 h SBP: −4.9 ± 2.2 mmHg, PWV: −0.32 ± 0.17 m/s) and again after 8 h post-ingestion. Large inter-individual variation in responses was found [intra-cluster correlation coefficients (ICC): 0.41, 0.41]. When analyzing single individuals’ datasets, there was also considerable between-day variation in individual responses that varied greatly between subjects (ICC: 0–0.30, 0–0.22, 0–0.45). Effect sizes inversely correlated with baseline blood pressure values both between- and within-subjects. The data confirm that cocoa can decrease blood pressure and arterial stiffness in everyday life when elevated within the normal range. The large inter- and intra-individual variation in responses calls for more personalized nutritional intervention strategies.
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Affiliation(s)
- Mariam Bapir
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Paola Campagnolo
- Department of Biochemical Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Ana Rodriguez-Mateos
- Department of Nutritional Sciences, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Simon S. Skene
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Christian Heiss
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
- Vascular Department, Surrey and Sussex NHS Healthcare Trust, Redhill, United Kingdom
- *Correspondence: Christian Heiss,
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Jamieson L, Harrop E, Liossi C, Boyce K, Mitchell L, Johnson M, Jani Y, Akinyooye V, Skene SS, Wong ICK, Howard RF, Oulton K. Carer preferences of route of administration of transmucosal diamorphine and willingness to take part in a randomised controlled trial: an interview study (DIPPER). BMC Palliat Care 2022; 21:78. [PMID: 35581660 PMCID: PMC9110942 DOI: 10.1186/s12904-022-00951-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/28/2022] [Indexed: 11/30/2022] Open
Abstract
Background Children and young people are usually given liquid morphine by mouth for breakthrough pain, which can take thirty minutes to work. A faster-acting, quickly absorbed, needle-free pain medicine, that is easy to administer is needed such as transmucosal (sublingual, buccal, intranasal) diamorphine. Research evidence relating to the administration of medication for breakthrough pain in children and young people is limited. This study aims to describe the experiences and preferences of parents and/or children and young people regarding the route of administration of diamorphine, barriers and facilitators comparative to oral morphine, and participation in a randomised controlled trial. Methods In-depth, semi-structured interviews with parents and/or children and young people at home or hospital/hospice. Results Thirteen interviews with: nine mothers, one father, and three sets of parents jointly. No interviews took place with a child/young person. Most families had experience of the buccal route which was effective in ease of administration and time to control pain. The intranasal route was preferred by parents irrespective of experience. Parents’ willingness for their child to take part in a trial depended on the time commitment, their child’s pain trajectory and the stability of analgesic requirements. Conclusion A randomised controlled trial of oral morphine versus transmucosal diamorphine would need to consider trial logistics, especially time commitment. Parents felt that the trial should be introduced initially by the clinical team, with written information from the research team, and sufficient time to ask questions. Patients who had discontinued oral morphine because of side effects, or those with gastrointestinal failure, should be excluded. Maintaining stability in pain management was essential to families, so the timing of the trial is a potential issue.
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Jones CJ, O'Donnell N, John M, Cooke D, Stewart R, Hale L, Skene SS, Kanumakala S, Harrington M, Satherley RM. PaRent InterventiOn to pRevent dIsordered eating in children with TYpe 1 diabetes (PRIORITY): Study protocol for a feasibility randomised controlled trial. Diabet Med 2022; 39:e14738. [PMID: 34741779 DOI: 10.1111/dme.14738] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
AIMS Increasing evidence suggests that children and young people with type 1 diabetes (T1D) are at greater risk of disordered eating compared to children without T1D. Disordered eating in T1D has been linked to impaired wellbeing, increased health service use and early mortality. To address this problem, we will co-develop a psycho-education intervention for parents of children and young people with T1D, informed by the Information Motivation Behavioural Skills model. METHODS The objective of this study is to assess the feasibility and acceptability of the intervention compared to a waitlist control group using a feasibility randomised controlled trial (RCT) design. We aim to recruit 70 parents of children and young people with T1D (11-14 years), 35 in each arm. Those assigned to the intervention will be invited to participate in two workshops of 2 h each. Parents will be asked to complete outcome measures regarding eating habits, diabetes management, as well as a questionnaire based on the Information Motivation Behavioural Skills model which provides a theoretical foundation for the intervention. These will be completed at baseline, 1- and 3-month post-intervention. Children and young people will be asked to complete questionnaires on their eating behaviours at the same time intervals. Parents randomised to receive the intervention will be invited to take part in interviews to feedback on the intervention and research protocol acceptability. CONCLUSION It is anticipated that the psycho-education intervention aimed at parents will help prevent the development of disordered eating in children and young people with T1D and improve parental wellbeing. The results of this feasibility trial will determine whether this intervention approach is acceptable to families living with T1D, and whether a definitive RCT of intervention effectiveness is justified. Qualitative findings will be used to refine the intervention and study protocols. TRIAL REGISTRATION This protocol has been registered with ClinicalTrials.gov [Identifier: NCT04741568].
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Affiliation(s)
| | | | - Mary John
- School of Psychology, University of Surrey, Guildford, UK
- Sussex Partnership NHS Foundation Trust, Research and Development Department, Sussex Education Centre, Hove, UK
| | - Debbie Cooke
- School of Health Sciences, University of Surrey, Guildford, UK
| | - Rose Stewart
- Betsi Cadwaladr University Health Board, Wrexham, Wales, UK
| | - Lucy Hale
- School of Psychology, University of Surrey, Guildford, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Shankar Kanumakala
- Royal Alexandra Children's Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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20
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Balouch S, Dijk DA, Rusted J, Skene SS, Tabet N, Dijk D. Night‐to‐night variation in sleep associates with day‐to‐day variation in vigilance, cognition, memory, and behavioral problems in Alzheimer's disease. Alz & Dem Diag Ass & Dis Mo 2022; 14:e12303. [PMID: 35603140 PMCID: PMC9109375 DOI: 10.1002/dad2.12303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/09/2022] [Accepted: 02/24/2022] [Indexed: 11/05/2022]
Abstract
Introduction Sleep disturbances are commonly reported in people living with Alzheimer's disease (AD), but it is currently unknown whether night‐to‐night variation in sleep predicts day‐to‐day variation in vigilance, cognition, mood, and behavior (daytime measures). Methods Subjective and objective sleep and daytime measures were collected daily for 2 weeks in 15 participants with mild AD, eight participants with mild cognitive impairment (MCI), and 22 participants with no cognitive impairment (NCI). Associations between daytime measures and four principal components of sleep (duration, quality, continuity, and latency) were quantified using mixed‐model regression. Results Sleepiness, alertness, contentedness, everyday memory errors, serial subtraction, and behavioral problems were predicted by at least one of the components of sleep, and in particular sleep duration and continuity. Associations between variations in sleep and daytime measures were linear or quadratic and often different between participants with AD and those with NCI. Discussion These findings imply that daytime functioning in people with AD may be improved by interventions that target sleep continuity.
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Affiliation(s)
- Sara Balouch
- Centre for Dementia Studies Brighton & Sussex Medical School Brighton UK
- School of Humanities and Social Science University of Brighton Brighton UK
| | - Dylan A.D. Dijk
- Surrey Clinical Trials Unit Department of Clinical and Experimental Medicine University of Surrey Guildford UK
| | | | - Simon S. Skene
- Surrey Clinical Trials Unit Department of Clinical and Experimental Medicine University of Surrey Guildford UK
| | - Naji Tabet
- Centre for Dementia Studies Brighton & Sussex Medical School Brighton UK
| | - Derk‐Jan Dijk
- Surrey Sleep Research Centre Department of Clinical and Experimental Medicine University of Surrey Guildford UK
- UK Dementia Research Institute Care Research and Technology Centre Imperial College London and the University of Surrey Guildford UK
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Chan AYL, Ge M, Harrop E, Johnson M, Oulton K, Skene SS, Wong ICK, Jamieson L, Howard RF, Liossi C. Pain assessment tools in paediatric palliative care: A systematic review of psychometric properties and recommendations for clinical practice. Palliat Med 2022; 36:30-43. [PMID: 34965753 PMCID: PMC8796159 DOI: 10.1177/02692163211049309] [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: 11/22/2022]
Abstract
BACKGROUND Assessing pain in infants, children and young people with life-limiting conditions remains a challenge due to diverse patient conditions, types of pain and often a reduced ability or inability of patients to communicate verbally. AIM To systematically identify pain assessment tools that are currently used in paediatric palliative care and examine their psychometric properties and feasibility and make recommendations for clinical practice. DESIGN A systematic literature review and evaluation of psychometric properties of pain assessment tools of original peer-reviewed research published from inception of data sources to April 2021. DATA SOURCES PsycINFO via ProQuest, Web of Science Core, Medline via Ovid, EMBASE, BIOSIS and CINAHL were searched from inception to April 2021. Hand searches of reference lists of included studies and relevant reviews were performed. RESULTS From 1168 articles identified, 201 papers were selected for full-text assessment. Thirty-four articles met the eligibility criteria and we examined the psychometric properties of 22 pain assessment tools. Overall, the Faces Pain Scale-Revised (FPS-R) had high cross-cultural validity, construct validity (hypothesis testing) and responsiveness; while the Faces, Legs, Activity, Cry and Consolability (FLACC) scale and Paediatric Pain Profile (PPP) had high internal consistency, criterion validity, reliability and responsiveness. The number of studies per psychometric property of each pain assessment tool was limited and the methodological quality of included studies was low. CONCLUSION Balancing aspects of feasibility and psychometric properties, the FPS-R is recommended for self-assessment, and the FLACC scale/FLACC Revised and PPP are the recommended observational tools in their respective age groups.
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Affiliation(s)
- Adrienne YL Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Pak Shek Kok, Hong Kong
- Groningen Research Institute of Pharmacy, Unit of Pharmacotherapy, Epidemiology and Economics, University of Groningen, Groningen, The Netherlands
| | - Mengqin Ge
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Emily Harrop
- Helen & Douglas House, Oxford, UK
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Margaret Johnson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Kate Oulton
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Surrey, UK
| | - Ian CK Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Pak Shek Kok, Hong Kong
- Research Department of Pratice & Policy, University College London School of Pharmacy, London, UK
- Centre for Medicines Optimisation Research and Education, University College London School of Pharmacy and University College London Hospital, London, UK
| | - Liz Jamieson
- Research Department of Pratice & Policy, University College London School of Pharmacy, London, UK
- Centre for Medicines Optimisation Research and Education, University College London School of Pharmacy and University College London Hospital, London, UK
| | - Richard F Howard
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Christina Liossi
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- School of Psychology, University of Southampton, Southampton, UK
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Faithfull S, Cockle-Hearne J, Lemanska A, Otter S, Skene SS. Randomised controlled trial to investigate the effectiveness of the symptom management after radiotherapy (SMaRT) group intervention to ameliorate lower urinary tract symptoms in men treated for prostate cancer. Support Care Cancer 2021; 30:3165-3176. [PMID: 34932140 PMCID: PMC8857109 DOI: 10.1007/s00520-021-06749-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/07/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE To evaluate the effectiveness of the symptom management after radiotherapy (SMaRT) group intervention to improve urinary symptoms in men with prostate cancer. METHODS The randomised controlled trial (RCT) recruited men from one radiotherapy centre in the UK after curative radiotherapy or brachytherapy and with moderate to severe urinary symptoms defined as scores ≥ 8 on the International Prostate Symptom Score (IPSS) questionnaire. Sixty-three men were randomised either; to SMaRT, a 10-week symptom-management intervention including group support, education, pelvic floor muscle exercises, or a care-as-usual group. The primary outcome was the IPSS at 6 months from baseline assessment. Secondary outcomes were IPSS at 3 months, and International Continence Society Male Short Form (ICS), European Organisation for Research and Treatment of Cancer Quality of Life prostate scale (EORTC QLQ-PR25), EORTC QLQ-30 and Self-Efficacy for Symptom Control Inventory (SESCI) at 3 and 6 months from baseline. Analysis of covariance (ANCOVA) was used to analyse the effect of the intervention. RESULTS SMaRT group intervention did not improve urinary symptoms as measured by IPSS at 6-months. The adjusted difference was - 2.5 [95%CI - 5.0 to 0.0], p = 0.054. Significant differences were detected at 3 months in ICS voiding symptoms (- 1.1 [- 2.0 to - 0.2], p = 0.017), ICS urinary incontinence (- 1.0 [- 1.8 to - 0.1], p = 0.029) and SESCI managing symptoms domain (13.5 [2.5 to 24.4], p = 0.017). No differences were observed at 6 months. CONCLUSIONS SMaRT group intervention provided short-term benefit in urinary voiding and continence and helped men manage symptoms but was not effective long term.
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Affiliation(s)
- Sara Faithfull
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, Surrey, UK.
| | - Jane Cockle-Hearne
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, Surrey, UK
| | - Agnieszka Lemanska
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, Surrey, UK
| | - Sophie Otter
- Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX, Surrey, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Egerton Road, Guildford, GU2 7XP, UK
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23
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Jamieson L, Harrop E, Johnson M, Liossi C, Mott C, Oulton K, Skene SS, Wong ICK, Howard RF. Healthcare professionals' views of the use of oral morphine and transmucosal diamorphine in the management of paediatric breakthrough pain and the feasibility of a randomised controlled trial: A focus group study (DIPPER). Palliat Med 2021; 35:1118-1125. [PMID: 33845654 PMCID: PMC8188993 DOI: 10.1177/02692163211008737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Oral morphine is frequently used for breakthrough pain but the oral route is not always available and absorption is slow. Transmucosal diamorphine is administered by buccal, sublingual or intranasal routes, and rapidly absorbed. AIM To explore the perspectives of healthcare professionals in the UK caring for children with life-limiting conditions concerning the assessment and management of breakthrough pain; prescribing and administration of transmucosal diamorphine compared with oral morphine; and the feasibility of a comparative clinical trial. DESIGN/ PARTICIPANTS Three focus groups, analysed using a Framework approach. Doctors, nurses and pharmacists (n = 28), caring for children with life-limiting illnesses receiving palliative care, participated. RESULTS Oral morphine is frequently used for breakthrough pain across all settings; with transmucosal diamorphine largely limited to use in hospices or given by community nurses, predominantly buccally. Perceived advantages of oral morphine included confidence in its use with no requirement for specific training; disadvantages included tolerability issues, slow onset, unpredictable response and unsuitability for patients with gastrointestinal failure. Perceived advantages of transmucosal diamorphine were quick onset and easy administration; barriers included lack of licensed preparations and prescribing guidance with fears over accountability of prescribers, and potential issues with availability, preparation and palatability. Factors potentially affecting recruitment to a trial were patient suitability and onerousness for families, trial design and logistics, staff time and clinician engagement. CONCLUSIONS There were perceived advantages to transmucosal diamorphine, but there is a need for access to a safe preparation. A clinical trial would be feasible provided barriers were overcome.
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Affiliation(s)
- Liz Jamieson
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
- UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
| | - Emily Harrop
- Helen & Douglas House Hospice, Oxford, UK
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Margaret Johnson
- Patient & Public Representative c/o Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Christina Liossi
- School of Psychology, University of Southampton, Southampton, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Christine Mott
- Hummingbird House Hospice, Brisbane, Queensland, Australia
- Children’s Health Queensland Hospital and Health Service, Paediatric Palliative Care Service
| | - Kate Oulton
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Simon S. Skene
- Surrey Clinical Trials Unit, University of Surrey, Surrey, UK
| | - Ian CK Wong
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
- UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
- Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong
| | - Richard F Howard
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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24
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Uwins C, Michael A, Skene SS, Bhandoria G, Wiggans AJ, Butler-Manuel S. Minimally invasive surgery (robotic or laparoscopic) versus laparotomy for advanced ovarian cancer. Hippokratia 2021. [DOI: 10.1002/14651858.cd013872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Christina Uwins
- Department of Gynaecological Oncology; Royal Surrey NHS Foundation Trust; Guildford UK
| | - Agnieszka Michael
- School of Biosciences and Medicine; University of Surrey; Guildford UK
| | - Simon S Skene
- Department of Clinical and Experimental Medicine; University of Surrey; Guildford UK
| | - Geetu Bhandoria
- Gynecologic Oncology & Obstetrics; Command Hospital & Armed Forces Medical College; Maharashtra India
| | - Alison J Wiggans
- Department of Obstetrics and Gynaecology; Musgrove Park Hospital; Taunton UK
| | - Simon Butler-Manuel
- Department of Gynaecological Oncology; Royal Surrey NHS Foundation Trust; Guildford UK
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Kelly C, Pericleous M, Ahmed A, Vandrevala T, Hendy J, Shafi S, Skene SS, Verma S, Edge C, Nicholls M, Gore C, de Lusignan S, Ala A. Improving uptake of hepatitis B and hepatitis C testing in South Asian migrants in community and faith settings using educational interventions-A prospective descriptive study. Int J Infect Dis 2020; 100:264-272. [PMID: 32861830 DOI: 10.1016/j.ijid.2020.08.059] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/19/2020] [Accepted: 08/22/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic viral hepatitis (CVH) is a leading contributor to the UK liver disease epidemic, with global migration from high prevalence areas (e.g., South Asia). Despite international guidance for testing high-risk groups in line with elimination targets, there is no consensus on how to achieve this. The objectives of this study were to assess the following: (1) the feasibility of recruiting South Asian migrants to view an educational film on CVH, (2) the effectiveness of the film in promoting testing and increasing knowledge of CVH, and (3) the methodological issues relevant to scale-up to a randomized controlled trial. METHODS South Asian migrants were recruited to view the film (intervention) in community venues (primary care, religious, community), with dried blood spot CVH testing offered immediately afterwards. Pre/post-film questionnaires assessed the effectiveness of the intervention. RESULTS Two hundred and nineteen first-generation migrants ≥18 years of age (53% female) were recruited to view the film at the following sites: religious, n = 112 (51%), community n = 98 (45%), and primary care, n = 9 (4%). One hundred and eighty-four (84%) underwent CVH testing; hepatitis B core antibody or hepatitis C antibody positivity demonstrated exposure in 8.5%. Pre-intervention (n = 173, 79%) and post-intervention (n = 154, 70%) questionnaires were completed. CONCLUSIONS This study demonstrated the feasibility of recruiting first-generation migrants to view a community-based educational film promoting CVH testing in this higher risk group, confirming the value of developing interventions to facilitate the global World Health Organization plan for targeted case finding and elimination, and a future randomized controlled trial. We highlight the importance of culturally relevant interventions including faith and culturally sensitive settings, which appear to minimize logistical issues and effectively engage minority groups, allowing ease of access to individuals 'at risk'.
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Affiliation(s)
- Claire Kelly
- Department of Gastroenterology and Hepatology, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK; Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Marinos Pericleous
- Department of Gastroenterology and Hepatology, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK; Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Ayesha Ahmed
- Brunel Business School, Brunel University, London, UK
| | | | - Jane Hendy
- Brunel Business School, Brunel University, London, UK
| | - Shuja Shafi
- Research and Documentation Committee, The Muslim Council of Britain, London, UK
| | - Simon S Skene
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School and Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital, Brighton, UK
| | - Chantal Edge
- Institute of Epidemiology and Health Care, UCL, London, UK
| | | | | | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Royal College of General Practitioners Research and Surveillance Centre, London, UK
| | - Aftab Ala
- Department of Gastroenterology and Hepatology, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK; Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK.
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Becares N, Härmälä S, China L, Colas RA, Maini AA, Bennet K, Skene SS, Shabir Z, Dalli J, O’Brien A. Immune Regulatory Mediators in Plasma from Patients With Acute Decompensation Are Associated With 3-Month Mortality. Clin Gastroenterol Hepatol 2020; 18:1207-1215.e6. [PMID: 31446184 PMCID: PMC7196929 DOI: 10.1016/j.cgh.2019.08.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/30/2019] [Accepted: 08/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Infection is a common cause of death in patients with cirrhosis. We investigated the association between the innate immune response and death within 3 months of hospitalization. METHODS Plasma samples were collected on days 1, 5, 10, and 15 from participants recruited into the albumin to prevent infection in chronic liver failure feasibility study. Patients with acute decompensated cirrhosis were given albumin infusions at 10 hospitals in the United Kingdom. Data were obtained from 45 survivors and 27 non-survivors. We incubated monocyte-derived macrophages from healthy individuals with patients' plasma samples and measured activation following lipopolysaccharide administration, determined by secretion of tumor necrosis factor and soluble mediators of inflammation. Each analysis included samples from 4 to 14 patients. RESULTS Plasma samples from survivors vs non-survivors had different inflammatory profiles. Levels of prostaglandin E2 were high at times of patient hospitalization and decreased with albumin infusions. Increased levels of interleukin 4 (IL4) in plasma collected at day 5 of treatment were associated with survival at 3 months. Incubation of monocyte-derived macrophages with day 5 plasma from survivors, pre-incubated with a neutralizing antibody against IL4, caused a significant increase in tumor necrosis factor production to the level of non-survivor plasma. Although baseline characteristics were similar, non-survivors had higher white cell counts and levels of C-reactive protein and renal dysfunction. CONCLUSIONS We identified profiles of inflammatory markers in plasma that are associated with 3-month mortality in patients with acute decompensated cirrhosis given albumin. Increases in prostaglandin E2 might promote inflammation within the first few days after hospitalization, and increased levels of plasma IL4 at day 5 are associated with increased survival. Clinicaltrialsregister.eu: EudraCT 2014-002300-24.
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Affiliation(s)
- Natalia Becares
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, United Kingdom.
| | - Suvi Härmälä
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Louise China
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, United Kingdom
| | - Romain A. Colas
- Lipid Mediator Unit, Center for Biochemical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, United Kingdom
| | - Alexander A. Maini
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, United Kingdom
| | - Kate Bennet
- Comprehensive Clinical Trials Unit, University College London, London, United Kingdom
| | - Simon S. Skene
- Comprehensive Clinical Trials Unit, University College London, London, United Kingdom
| | - Zainib Shabir
- Comprehensive Clinical Trials Unit, University College London, London, United Kingdom
| | - Jesmond Dalli
- Lipid Mediator Unit, Center for Biochemical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, United Kingdom
| | - Alastair O’Brien
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, United Kingdom
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Muller P, Skene SS, Chowdhury K, Cro S, Goldberg AJ, Doré CJ. A randomised, multi-centre trial of total ankle replacement versus ankle arthrodesis in the treatment of patients with end stage ankle osteoarthritis (TARVA): statistical analysis plan. Trials 2020; 21:197. [PMID: 32070409 PMCID: PMC7029552 DOI: 10.1186/s13063-019-3973-4] [Citation(s) in RCA: 10] [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] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The total ankle replacement versus ankle arthrodesis (TARVA) trial aims to determine which surgical procedure confers the greatest improvement in pain-free function for patients with end-stage ankle osteoarthritis. Both procedures are effective but there has not yet been a direct comparison to establish which is superior. This article describes the statistical analysis plan for this trial as an update to the published protocol. It is written prior to the end of patient follow-up, while the outcome of the trial is still unknown. DESIGN AND METHODS TARVA is a randomised, un-blinded, parallel group trial of total ankle replacement versus ankle arthrodesis. The primary outcome is the Manchester-Oxford Foot Questionnaire walking/standing domain score at 52 weeks post-surgery. Secondary outcomes include measures of pain, social interaction, physical function, quality of life, and range of motion. We describe in detail the statistical aspects of TARVA: the outcome measures, the sample size calculation, general analysis principles including treatment of missing data, the planned descriptive statistics and statistical models, and planned subgroup and sensitivity analyses. DISCUSSION The TARVA statistical analysis will provide comprehensive and precise information on the relative effectiveness of the two treatments. The plan will be implemented in January 2020 when follow-up for the trial is completed. TRIAL REGISTRATION ISRCTN registry number 60672307, ClinicalTrials.gov registration number NCT02128555. Registered 1 May 2014. Recruitment started in January 2015 and ended in January 2019.
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Affiliation(s)
- Patrick Muller
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Simon S. Skene
- Department of Clinical and Experimental Medicine, School of Biosciences and Medicine, University of Surrey, Guildford, Surrey UK
| | - Kashfia Chowdhury
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Andrew J. Goldberg
- UCL Institute of Orthopaedics and Musculoskeletal Science (IOMS), Royal National Orthopaedic Hospital (RNOH), London, UK
| | - Caroline J. Doré
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
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28
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Athauda D, Gulyani S, Karnati HK, Li Y, Tweedie D, Mustapic M, Chawla S, Chowdhury K, Skene SS, Greig NH, Kapogiannis D, Foltynie T. Utility of Neuronal-Derived Exosomes to Examine Molecular Mechanisms That Affect Motor Function in Patients With Parkinson Disease: A Secondary Analysis of the Exenatide-PD Trial. JAMA Neurol 2020; 76:420-429. [PMID: 30640362 DOI: 10.1001/jamaneurol.2018.4304] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Exenatide, a glucagon-like peptide 1 agonist used in type 2 diabetes, was recently found to have beneficial effects on motor function in a randomized, placebo-controlled trial in Parkinson disease (PD). Accumulating evidence suggests that impaired brain insulin and protein kinase B (Akt) signaling play a role in PD pathogenesis; however, exploring the extent to which drugs engage with putative mechnisms in vivo remains a challenge. Objective To assess whether participants in the Exenatide-PD trial have augmented activity in brain insulin and Akt signaling pathways. Design, Setting, and Participants Serum samples were collected from 60 participants in the single-center Exenatide-PD trial (June 18, 2014, to June 16, 2016), which compared patients with moderate PD randomized to 2 mg of exenatide once weekly or placebo for 48 weeks followed by a 12-week washout period. Serum extracellular vesicles, including exosomes, were extracted, precipitated, and enriched for neuronal source by anti-L1 cell adhesion molecule antibody absorption, and proteins of interest were evaluated using electrochemiluminescence assays. Statistical analysis was performed from May 1, 2017, to August 31, 2017. Main Outcomes and Measures The main outcome was augmented brain insulin signaling that manifested as a change in tyrosine phosphorylated insulin receptor substrate 1 within neuronal extracellular vesicles at the end of 48 weeks of exenatide treatment. Additional outcome measures were changes in other insulin receptor substrate proteins and effects on protein expression in the Akt and mitogen-activated protein kinase pathways. Results Sixty patients (mean [SD] age, 59.9 [8.4] years; 43 [72%] male) participated in the study: 31 in the exenatide group and 29 in the placebo group (data from 1 patient in the exenatide group were excluded). Patients treated with exenatide had augmented tyrosine phosphorylation of insulin receptor substrate 1 at 48 weeks (0.27 absorbance units [AU]; 95% CI, 0.09-0.44 AU; P = .003) and 60 weeks (0.23 AU; 95% CI, 0.05-0.41 AU; P = .01) compared with patients receiving placebo. Exenatide-treated patients had elevated expression of downstream substrates, including total Akt (0.35 U/mL; 95% CI, 0.16-0.53 U/mL; P < .001) and phosphorylated mechanistic target of rapamycin (mTOR) (0.22 AU; 95% CI, 0.04-0.40 AU; P = .02). Improvements in Movement Disorders Society Unified Parkinson's Disease Rating Scale part 3 off-medication scores were associated with levels of total mTOR (F4,50 = 5.343, P = .001) and phosphorylated mTOR (F4,50 = 4.384, P = .04). Conclusions and Relevance The results of this study are consistent with target engagement of brain insulin, Akt, and mTOR signaling pathways by exenatide and provide a mechanistic context for the clinical findings of the Exenatide-PD trial. This study suggests the potential of using exosome-based biomarkers as objective measures of target engagement in clinical trials using drugs that target neuronal pathways.
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Affiliation(s)
- Dilan Athauda
- Department of Clinical and Movement Neurosciences, University College London Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Seema Gulyani
- Laboratory of Neurosciences, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Hanuma Kumar Karnati
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Yazhou Li
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - David Tweedie
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Maja Mustapic
- Laboratory of Neurosciences, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Sahil Chawla
- Laboratory of Neurosciences, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Kashfia Chowdhury
- University College London Comprehensive Clinical Trials Unit, London, United Kingdom
| | - Simon S Skene
- University College London Comprehensive Clinical Trials Unit, London, United Kingdom.,School of Biosciences and Medicine, University of Surrey, Kent, United Kingdom
| | - Nigel H Greig
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Dimitrios Kapogiannis
- Laboratory of Neurosciences, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Thomas Foltynie
- Department of Clinical and Movement Neurosciences, University College London Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Athauda D, Maclagan K, Budnik N, Zampedri L, Hibbert S, Skene SS, Chowdhury K, Aviles-Olmos I, Limousin P, Foltynie T. What Effects Might Exenatide have on Non-Motor Symptoms in Parkinson's Disease: A Post Hoc Analysis. J Parkinsons Dis 2019; 8:247-258. [PMID: 29843254 DOI: 10.3233/jpd-181329] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Exenatide is a GLP-1 receptor agonist that was recently studied for potential disease-modifying effects in a randomised, placebo-controlled clinical trial in patients with moderate stage Parkinson's disease, and showed positive effects on the motor severity of the disease which were sustained 12 weeks beyond the period of exenatide exposure. Analysis of pre-defined secondary outcomes revealed no statistically significant differences between patients treated with exenatide in total non-motor symptom burden and overall quality of life measures. OBJECTIVE The response of individual non-motor symptoms to an intervention may vary and thus this post hoc analysis was conducted to explore the possible effects of exenatide compared to placebo on individual non-motor symptoms. RESULTS Compared to placebo, patients treated with exenatide-once weekly had greater improvements in individual domains assessing mood/depression across all observer-rated outcome measures after 48 weeks including the "mood/apathy" domain of the NMSS, - 3.3 points (95% CI - 6.2, - 0.4), p = 0.026; the "mood" score (Q1.3+Q1.4 of the MDS-UPDRS Part 1), - 0.3 points (95% CI - 0.6, - 0.1), p = 0.034; and a trend in the MADRS total score, - 1.7 points (95% CI - 3.6, 0.2), p = 0.071. In addition, there was an improvement in the "emotional well-being" domain of the PDQ-39 of 5.7 points ((95% CI - 11.3, - 0.1), p = 0.047 though these improvements were not sustained 12 weeks after exenatide withdrawal. At 48 weeks these changes were of a magnitude that would be subjectively meaningful to patients and were not associated with changes in motor severity or other factors, suggesting exenatide may exert independent effects on mood dysfunction. CONCLUSIONS These exploratory findings will contribute to the design of future trials to confirm the extent of motor and non-motor symptom effects of exenatide in larger cohorts of patients.
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Affiliation(s)
- Dilan Athauda
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | | | - Natalia Budnik
- Leonard Wolfson Experimental Neuroscience Centre, London, UK
| | - Luca Zampedri
- Leonard Wolfson Experimental Neuroscience Centre, London, UK
| | | | - Simon S Skene
- UCL Comprehensive Clinical Trials Unit (UCL CCTU).,University of Surrey, Surrey Clinical Trials Unit, UK
| | | | - Iciar Aviles-Olmos
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Patricia Limousin
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Rodriguez-Mateos A, Weber T, Skene SS, Ottaviani JI, Crozier A, Kelm M, Schroeter H, Heiss C. Assessing the respective contributions of dietary flavanol monomers and procyanidins in mediating cardiovascular effects in humans: randomized, controlled, double-masked intervention trial. Am J Clin Nutr 2018; 108:1229-1237. [PMID: 30358831 PMCID: PMC6290365 DOI: 10.1093/ajcn/nqy229] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/13/2018] [Indexed: 01/21/2023] Open
Abstract
Background Flavanols are an important class of food bioactives that can improve vascular function even in healthy subjects. Cocoa flavanols (CFs) are composed principally of the monomer (-)-epicatechin (∼20%), with a degree of polymerisation (DP) of 1 (DP1), and oligomeric procyanidins (∼80%, DP2-10). Objective Our objective was to investigate the relative contribution of procyanidins and (-)-epicatechin to CF intake-related improvements in vascular function in healthy volunteers. Design In a randomized, controlled, double-masked, parallel-group dietary intervention trial, 45 healthy men (aged 18-35 y) consumed the following once daily for 1 mo: 1) a DP1-10 cocoa extract containing 130 mg (-)-epicatechin and 560 mg procyanidins, 2) a DP2-10 cocoa extract containing 20 mg (-)-epicatechin and 540 mg procyanidins, or 3) a control capsule, which was flavanol-free but had identical micro- and macronutrient composition. Results Consumption of DP1-10, but not of either DP2-10 or the control capsule, significantly increased flow-mediated vasodilation (primary endpoint) and the concentration of structurally related (-)-epicatechin metabolites (SREMs) in the circulatory system while decreasing pulse wave velocity and blood pressure. Total cholesterol significantly decreased after daily intake of both DP1-10 and DP2-10 as compared with the control. Conclusions CF-related improvements in vascular function are predominantly related to the intake of flavanol monomers and circulating SREMs in healthy humans but not to the more abundant procyanidins and gut microbiome-derived CF catabolites. Reduction in total cholesterol was linked to consumption of procyanidins but not necessarily to that of (-)-epicatechin. This trial was registered at clinicaltrials.gov as NCT02728466.
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Affiliation(s)
- Ana Rodriguez-Mateos
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University of Dusseldorf, Dusseldorf, Germany
| | - Timon Weber
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University of Dusseldorf, Dusseldorf, Germany
| | - Simon S Skene
- University of Surrey, Faculty of Health and Medical Sciences, Guildford, United Kingdom
| | | | - Alan Crozier
- Nutrition Department, University of California, Davis, Davis, CA
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University of Dusseldorf, Dusseldorf, Germany
| | | | - Christian Heiss
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University of Dusseldorf, Dusseldorf, Germany,University of Surrey, Faculty of Health and Medical Sciences, Guildford, United Kingdom,Address correspondence to CH (e-mail: )
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China L, Skene SS, Bennett K, Shabir Z, Hamilton R, Bevan S, Chandler T, Maini AA, Becares N, Gilroy D, Forrest EH, O’Brien A. ATTIRE: Albumin To prevenT Infection in chronic liveR failurE: study protocol for an interventional randomised controlled trial. BMJ Open 2018; 8:e023754. [PMID: 30344180 PMCID: PMC6196858 DOI: 10.1136/bmjopen-2018-023754] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Circulating prostaglandin E2 levels are elevated in acutely decompensated cirrhosis and have been shown to contribute to immune suppression. Albumin binds to and inactivates this immune-suppressive lipid mediator. Human albumin solution (HAS) could thus be repurposed as an immune-restorative drug in these patients.This is a phase III randomised controlled trial (RCT) to verify whether targeting a serum albumin level of ≥35 g/L in hospitalised patients with decompensated cirrhosis using repeated intravenous infusions of 20% HAS will reduce incidence of infection, renal dysfunction and mortality for the treatment period (maximum 14 days or discharge if <14 days) compared with standard medical care. METHODS AND ANALYSIS Albumin To prevenT Infection in chronic liveR failurE stage 2 is a multicentre, open-label, interventional RCT. Patients with decompensated cirrhosis admitted to the hospital with a serum albumin of <30 g/L are eligible, subject to exclusion criteria. Patients randomised to intravenous HAS will have this administered, according to serum albumin levels, for up to 14 days or discharge. The infusion protocol aims to increase serum albumin to near-normal levels.The composite primary endpoint is: new infection, renal dysfunction or mortality within the trial treatment period. Secondary endpoints include mortality at up to 6 months, incidence of other organ failures, cost-effectiveness and quality of life outcomes and time to liver transplant. The trial will recruit 866 patients at more than 30 sites across the UK. ETHICSANDDISSEMINATION Research ethics approval was given by the London-Brent research ethics committee (ref: 15/LO/0104). The clinical trials authorisation was issued by the medicines and healthcare products regulatory agency (ref: 20363/0350/001-0001). The trial is registered with the European Medicines Agency (EudraCT 2014-002300-24) and has been adopted by the National Institute for Health Research (ISRCTN 14174793). This manuscript refers to version 6.0 of the protocol. Results will be disseminated through peer-reviewed journals and international conferences. Recruitment of the first participant occurred on 25 January 2016.
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Affiliation(s)
- Louise China
- Division of Medicine, University College London, London, UK
| | - Simon S Skene
- School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Kate Bennett
- Comprehensive Clinical Trials Unit, UCL, London, UK
| | | | | | - Scott Bevan
- Comprehensive Clinical Trials Unit, UCL, London, UK
| | | | | | | | - Derek Gilroy
- Division of Medicine, University College London, London, UK
| | - Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
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Athauda D, Maclagan K, Budnik N, Zampedri L, Hibbert S, Aviles-Olmos I, Chowdhury K, Skene SS, Limousin P, Foltynie T. Post hoc analysis of the Exenatide-PD trial-Factors that predict response. Eur J Neurosci 2018; 49:410-421. [PMID: 30070753 DOI: 10.1111/ejn.14096] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/27/2018] [Accepted: 07/23/2018] [Indexed: 12/25/2022]
Abstract
Exenatide, a glucagon-like peptide-1 agonist and a licensed treatment for Type 2 diabetes significantly reduced deterioration in motor symptoms in patients with Parkinson's disease in a randomized, placebo-controlled trial. In addition, there were trends favouring the exenatide group in assessments of nonmotor symptoms, cognition, and quality of life. The aim of this exploratory post hoc analysis was to generate new hypotheses regarding (a) whether candidate baseline factors might predict the magnitude of response to exenatide; and (b) whether the beneficial effects of exenatide reported for the overall population are consistent in various subgroups of patients. Univariate and multivariate analyses were conducted to determine possible predictors of motor response to exenatide in this cohort. Potential treatment by subgroup interactions for changes in; motor severity, nonmotor symptoms, cognition, and quality of life after 48-weeks treatment with exenatide were evaluated among post hoc subgroups defined by age, motor phenotype, disease duration, disease severity, body mass index (BMI), and insulin resistance. In the subgroup analyses, exenatide once-weekly was associated with broadly improved outcome measures assessing motor severity, nonmotor symptoms, cognition, and quality of life across all subgroups, however, tremor-dominant phenotype and lower Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) Part-2 scores predicted greatest motor response to exenatide and there was an indication that patients with older age of onset and disease duration over 10 years responded less well. While patients with a range of demographic and clinical factors can potentially benefit from exenatide once-weekly, these data support an emphasis towards recruiting patients at earlier disease in future planned clinical trials of gluacagon-like peptide-1 (GLP-1) receptor agonists in Parkinson's disease (PD).
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Affiliation(s)
- Dilan Athauda
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology & The National Hospital for Neurology and Neurosurgery, London, UK
| | - Kate Maclagan
- UCL Comprehensive Clinical Trials Unit (UCL CCTU), London, UK
| | - Natalia Budnik
- Leonard Wolfson Experimental Neuroscience Centre, London, UK
| | - Luca Zampedri
- Leonard Wolfson Experimental Neuroscience Centre, London, UK
| | - Steve Hibbert
- UCL Comprehensive Clinical Trials Unit (UCL CCTU), London, UK
| | - Iciar Aviles-Olmos
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology & The National Hospital for Neurology and Neurosurgery, London, UK
| | | | - Simon S Skene
- UCL Comprehensive Clinical Trials Unit (UCL CCTU), London, UK.,School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Patricia Limousin
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology & The National Hospital for Neurology and Neurosurgery, London, UK
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology & The National Hospital for Neurology and Neurosurgery, London, UK
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Stern M, Broja M, Sansone R, Gröne M, Skene SS, Liebmann J, Suschek CV, Born M, Kelm M, Heiss C. Blue light exposure decreases systolic blood pressure, arterial stiffness, and improves endothelial function in humans. Eur J Prev Cardiol 2018; 25:1875-1883. [PMID: 30196723 DOI: 10.1177/2047487318800072] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIMS Previous studies have shown that ultraviolet light can lead to the release of nitric oxide from the skin and decrease blood pressure. In contrast to visible light the local application of ultraviolet light bears a cancerogenic risk. Here, we investigated whether whole body exposure to visible blue light can also decrease blood pressure and increase endothelial function in healthy subjects. METHODS In a randomised crossover study, 14 healthy male subjects were exposed on 2 days to monochromatic blue light or blue light with a filter foil (control light) over 30 minutes. We measured blood pressure (primary endpoint), heart rate, forearm vascular resistance, forearm blood flow, endothelial function (flow-mediated dilation), pulse wave velocity and plasma nitric oxide species, nitrite and nitroso compounds (secondary endpoints) during and up to 2 hours after exposure. RESULTS Blue light exposure significantly decreased systolic blood pressure and increased heart rate as compared to control. In parallel, blue light significantly increased forearm blood flow, flow-mediated dilation, circulating nitric oxide species and nitroso compounds while it decreased forearm vascular resistance and pulse wave velocity. CONCLUSION Whole body irradiation with visible blue light at real world doses improves blood pressure, endothelial function and arterial stiffness by nitric oxide released from photolabile intracutanous nitric oxide metabolites into circulating blood.
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Affiliation(s)
- Manuel Stern
- 1 Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany
| | - Melanie Broja
- 1 Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany
| | - Roberto Sansone
- 1 Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany
| | - Michael Gröne
- 1 Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany
| | - Simon S Skene
- 2 Department of Clinical and Experimental Medicine, Faculty of Health and Medical Science, University of Surrey, UK
| | | | - Christoph V Suschek
- 4 Department of Trauma and Hand Surgery, Medical Faculty, University Duesseldorf, Germany
| | - Matthias Born
- 3 Philips GmbH, Innovative Technologies, Germany.,5 Heinrich-Heine University, Germany
| | - Malte Kelm
- 1 Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany
| | - Christian Heiss
- 1 Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany.,2 Department of Clinical and Experimental Medicine, Faculty of Health and Medical Science, University of Surrey, UK.,6 Surrey and Sussex NHS Healthcare Trust, UK
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China L, Skene SS, Shabir Z, Maini A, Sylvestre Y, Bennett K, Bevan S, O'Beirne J, Forrest E, Portal J, Ryder S, Wright G, Gilroy DW, O'Brien A. Administration of Albumin Solution Increases Serum Levels of Albumin in Patients With Chronic Liver Failure in a Single-Arm Feasibility Trial. Clin Gastroenterol Hepatol 2018; 16:748-755.e6. [PMID: 28911947 PMCID: PMC6168936 DOI: 10.1016/j.cgh.2017.09.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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] [Received: 05/15/2017] [Revised: 08/21/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Infections are life-threatening to patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF). Patients with AD/ACLF have prostaglandin E2-mediated immune suppression, which can be reversed by administration of albumin; infusion of 20% human albumin solution (HAS) might improve outcomes of infections. We performed a feasibility study to determine optimal trial design, assess safety, and validate laboratory assessments of immune function to inform design of a phase 3 trial. METHODS We performed a prospective multicenter, single-arm, open-label trial of 79 patients with AD/ACLF and levels of albumin lower than 30 g/L, seen at 10 hospitals in the United Kingdom from May through December 2015. Patients were given daily infusions of 20% HAS, based on serum levels, for 14 days or until discharge from the hospital. Rates of infection, organ dysfunction, and in-hospital mortality were recorded. The primary end point was daily serum albumin level during the treatment period. Success would be demonstrated if 60% achieved and maintained serum albumin levels at or above 30 g/L on at least one third of days with recorded levels. RESULTS The patients' mean model for end-stage disease score was 20.9 ± 6.6. The primary end point (albumin ≥30 g/L on at least one third of days recorded) was achieved by 68 of the 79 patients; 75% of administrations were in accordance with suggested dosing regimen. Mean treatment duration was 10.3 days (104 ± 678 mL administered). There were 8 deaths and 13 serious adverse events, considered by the independent data-monitoring committee to be consistent with those expected. Twelve of 13 patients that developed either respiratory or cardiovascular dysfunction (based on ward-based clinical definitions) as their only organ dysfunction were alive at 30 days compared with 1 of 3 that developed renal dysfunction. Only 1 case of brain dysfunction was recorded. CONCLUSIONS In a feasibility trial, we found that administration of HAS increased serum levels of albumin in patients with AD/ACLF. The dosing regimen was acceptable at multiple sites and deemed safe by an independent data-monitoring committee. We also developed a robust system to record infections. The poor prognosis for patients with renal dysfunction was confirmed. However, patients with cardiovascular or respiratory dysfunction had good outcomes, which is counterintuitive. Severe encephalopathy appeared substantially under-reported, indicating that ward-based assessment of these parameters cannot be recorded with sufficient accuracy for use as a primary outcome in phase 3 trials. Trial registration no: EudraCT 2014-002300-24 and ISRCTN14174793.
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Affiliation(s)
- Louise China
- Division of Medicine, University College London, United Kingdom.
| | - Simon S Skene
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Zainib Shabir
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Alexander Maini
- Division of Medicine, University College London, United Kingdom
| | - Yvonne Sylvestre
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Kate Bennett
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Scott Bevan
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - James O'Beirne
- Royal Free National Health Service Trust, London, United Kingdom
| | - Ewan Forrest
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Jim Portal
- Bristol Royal Infirmary, Bristol, United Kingdom
| | - Steve Ryder
- Nottingham University Hospital, Nottingham, United Kingdom
| | - Gavin Wright
- Basildon University Hospital, Essex, United Kingdom
| | - Derek W Gilroy
- Division of Medicine, University College London, United Kingdom
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China L, Maini A, Skene SS, Shabir Z, Sylvestre Y, Colas RA, Ly L, Becares Salles N, Belloti V, Dalli J, Gilroy DW, O’Brien A. Albumin Counteracts Immune-Suppressive Effects of Lipid Mediators in Patients With Advanced Liver Disease. Clin Gastroenterol Hepatol 2018; 16:738-747.e7. [PMID: 28859868 PMCID: PMC6168974 DOI: 10.1016/j.cgh.2017.08.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/28/2017] [Accepted: 08/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF) have immune dysfunction, which increases their risk for infections; however, there are no effective treatments to restore their immune function. We investigated whether the potentially immune-restorative effects of albumin are mediated by its effects on prostaglandin E2 (PGE2) and other lipids. METHODS We analyzed bloods samples from 45 of 79 patients with AD/ACLF and serum levels of albumin less than 30 g/L for whom infusion of 20% human albumin solution (HAS) increased serum levels of albumin 30 g/L or more in a feasibility study of effects of 20% HAS. Immune function was determined by comparison of macrophage function following addition of plasma samples. We also used samples from 12 healthy individuals. We measured binding of plasma proteins to PGE2 and serum levels of endotoxin (lipopolysaccharide) and cytokines; using 10 patients' samples, we investigated the effects of PGE2 inhibitors. We performed a comprehensive lipid metabolomic analysis using samples from 10 different patients, before and after HAS administration. RESULTS At baseline, AD/ACLF patient plasma induced significantly lower production of tumor necrosis factor by healthy macrophages than plasma from healthy individuals (P < .0001). Plasma from patients after HAS infusion induced significantly higher levels of tumor necrosis factor production by macrophages (19.5 ± 4.8 ng/mL) compared with plasma collected before treatment (17.7 ± 4.5 ng/mL; P = .0013). There was a significantly lower proportion of plasma protein (albumin) binding to PGE2 from patients with AD/ACLF plasma (mean, 61.9%) compared with plasma from control subjects (77.1%; P = .0012). AD/ACLF plasma protein binding to PGE2 increased following HAS treatment compared with baseline (mean increase, 8.7%; P < .0001). Circulating levels of PGE2, lipopolysaccharide, and inflammatory or anti-inflammatory cytokines were higher in patients with AD/ACLF than healthy volunteers. Unexpectedly, HAS infusion had no effect on mediator levels. Principal component analysis of baseline levels of lipids that induce or resolve inflammation identified 2 distinct groups of patients that differed according to baseline plasma level of lipopolysaccharide. Sample analyses after HAS treatment indicated that albumin regulates circulating levels of lipid mediators, but this effect was distinct in each group. CONCLUSIONS Analysis of blood samples from patients with AD/ACLF participating in a feasibility study of 20% HAS infusions has shown that infusions to raise serum albumin above 30 g/L reversed plasma-mediated immune dysfunction by binding and inactivating PGE2. We also describe a method to classify the inflammatory response in AD/ACLF, based on lipid profile, which could improve identification of patients most likely to respond to HAS treatment. A randomized controlled trial is needed to determine whether these effects of HAS reduce infections in AD/ACLF. Trial registered with European Medicines Agency (EudraCT 2014-002300-24) and adopted by NIHR (ISRCTN14174793).
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Affiliation(s)
- Louise China
- Division of Medicine, University College London, London, United Kingdom.
| | - Alexander Maini
- Division of Medicine, University College London, London, United Kingdom
| | - Simon S. Skene
- University of London Comprehensive Clinical Trials Unit, London, United Kingdom
| | - Zainib Shabir
- University of London Comprehensive Clinical Trials Unit, London, United Kingdom
| | - Yvonne Sylvestre
- University of London Comprehensive Clinical Trials Unit, London, United Kingdom
| | - Romain A. Colas
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Lucy Ly
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | | | - Vittorio Belloti
- Division of Medicine, University College London, London, United Kingdom
| | - Jesmond Dalli
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Derek W. Gilroy
- Division of Medicine, University College London, London, United Kingdom
| | - Alastair O’Brien
- Division of Medicine, University College London, London, United Kingdom
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Athauda D, Maclagan K, Skene SS, Bajwa-Joseph M, Letchford D, Chowdhury K, Hibbert S, Budnik N, Zampedri L, Dickson J, Li Y, Aviles-Olmos I, Warner TT, Limousin P, Lees AJ, Greig NH, Tebbs S, Foltynie T. Exenatide once weekly versus placebo in Parkinson's disease: a randomised, double-blind, placebo-controlled trial. Lancet 2017; 390:1664-1675. [PMID: 28781108 DOI: 10.1016/s01406736(17)31585-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/27/2017] [Accepted: 05/09/2017] [Indexed: 05/26/2023]
Abstract
BACKGROUND Exenatide, a glucagon-like peptide-1 (GLP-1) receptor agonist, has neuroprotective effects in preclinical models of Parkinson's disease. We investigated whether these effects would be apparent in a clinical trial. METHODS In this single-centre, randomised, double-blind, placebo-controlled trial, patients with moderate Parkinson's disease were randomly assigned (1:1) to receive subcutaneous injections of exenatide 2 mg or placebo once weekly for 48 weeks in addition to their regular medication, followed by a 12-week washout period. Eligible patients were aged 25-75 years, had idiopathic Parkinson's disease as measured by Queen Square Brain Bank criteria, were on dopaminergic treatment with wearing-off effects, and were at Hoehn and Yahr stage 2·5 or less when on treatment. Randomisation was by web-based randomisation with a two strata block design according to disease severity. Patients and investigators were masked to treatment allocation. The primary outcome was the adjusted difference in the Movement Disorders Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor subscale (part 3) in the practically defined off-medication state at 60 weeks. All efficacy analyses were based on a modified intention-to-treat principle, which included all patients who completed any post-randomisation follow-up assessments. The study is registered at ClinicalTrials.gov (NCT01971242) and is completed. FINDINGS Between June 18, 2014, and March 13, 2015, 62 patients were enrolled and randomly assigned, 32 to exenatide and 30 to placebo. Our primary analysis included 31 patients in the exenatide group and 29 patients in the placebo group. At 60 weeks, off-medication scores on part 3 of the MDS-UPDRS had improved by 1·0 points (95% CI -2·6 to 0·7) in the exenatide group and worsened by 2·1 points (-0·6 to 4·8) in the placebo group, an adjusted mean difference of -3·5 points (-6·7 to -0·3; p=0·0318). Injection site reactions and gastrointestinal symptoms were common adverse events in both groups. Six serious adverse events occurred in the exenatide group and two in the placebo group, although none in either group were judged to be related to the study interventions. INTERPRETATION Exenatide had positive effects on practically defined off-medication motor scores in Parkinson's disease, which were sustained beyond the period of exposure. Whether exenatide affects the underlying disease pathophysiology or simply induces long-lasting symptomatic effects is uncertain. Exenatide represents a major new avenue for investigation in Parkinson's disease, and effects on everyday symptoms should be examined in longer-term trials. FUNDING Michael J Fox Foundation for Parkinson's Research.
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Affiliation(s)
- Dilan Athauda
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Kate Maclagan
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Simon S Skene
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | | | - Dawn Letchford
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Kashfia Chowdhury
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Steve Hibbert
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Natalia Budnik
- Leonard Wolfson Experimental Neuroscience Centre, London, UK
| | - Luca Zampedri
- Leonard Wolfson Experimental Neuroscience Centre, London, UK
| | - John Dickson
- Institute of Nuclear Medicine, University College London Hospitals NHS Trust, London, UK
| | - Yazhou Li
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Iciar Aviles-Olmos
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | | | - Patricia Limousin
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Andrew J Lees
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Nigel H Greig
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Susan Tebbs
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK.
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Athauda D, Maclagan K, Skene SS, Bajwa-Joseph M, Letchford D, Chowdhury K, Hibbert S, Budnik N, Zampedri L, Dickson J, Li Y, Aviles-Olmos I, Warner TT, Limousin P, Lees AJ, Greig NH, Tebbs S, Foltynie T. Exenatide once weekly versus placebo in Parkinson's disease: a randomised, double-blind, placebo-controlled trial. Lancet 2017; 390:1664-1675. [PMID: 28781108 PMCID: PMC5831666 DOI: 10.1016/s0140-6736(17)31585-4] [Citation(s) in RCA: 438] [Impact Index Per Article: 62.6] [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] [Received: 02/21/2017] [Revised: 04/27/2017] [Accepted: 05/09/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Exenatide, a glucagon-like peptide-1 (GLP-1) receptor agonist, has neuroprotective effects in preclinical models of Parkinson's disease. We investigated whether these effects would be apparent in a clinical trial. METHODS In this single-centre, randomised, double-blind, placebo-controlled trial, patients with moderate Parkinson's disease were randomly assigned (1:1) to receive subcutaneous injections of exenatide 2 mg or placebo once weekly for 48 weeks in addition to their regular medication, followed by a 12-week washout period. Eligible patients were aged 25-75 years, had idiopathic Parkinson's disease as measured by Queen Square Brain Bank criteria, were on dopaminergic treatment with wearing-off effects, and were at Hoehn and Yahr stage 2·5 or less when on treatment. Randomisation was by web-based randomisation with a two strata block design according to disease severity. Patients and investigators were masked to treatment allocation. The primary outcome was the adjusted difference in the Movement Disorders Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor subscale (part 3) in the practically defined off-medication state at 60 weeks. All efficacy analyses were based on a modified intention-to-treat principle, which included all patients who completed any post-randomisation follow-up assessments. The study is registered at ClinicalTrials.gov (NCT01971242) and is completed. FINDINGS Between June 18, 2014, and March 13, 2015, 62 patients were enrolled and randomly assigned, 32 to exenatide and 30 to placebo. Our primary analysis included 31 patients in the exenatide group and 29 patients in the placebo group. At 60 weeks, off-medication scores on part 3 of the MDS-UPDRS had improved by 1·0 points (95% CI -2·6 to 0·7) in the exenatide group and worsened by 2·1 points (-0·6 to 4·8) in the placebo group, an adjusted mean difference of -3·5 points (-6·7 to -0·3; p=0·0318). Injection site reactions and gastrointestinal symptoms were common adverse events in both groups. Six serious adverse events occurred in the exenatide group and two in the placebo group, although none in either group were judged to be related to the study interventions. INTERPRETATION Exenatide had positive effects on practically defined off-medication motor scores in Parkinson's disease, which were sustained beyond the period of exposure. Whether exenatide affects the underlying disease pathophysiology or simply induces long-lasting symptomatic effects is uncertain. Exenatide represents a major new avenue for investigation in Parkinson's disease, and effects on everyday symptoms should be examined in longer-term trials. FUNDING Michael J Fox Foundation for Parkinson's Research.
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Affiliation(s)
- Dilan Athauda
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Kate Maclagan
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Simon S Skene
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | | | - Dawn Letchford
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Kashfia Chowdhury
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Steve Hibbert
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Natalia Budnik
- Leonard Wolfson Experimental Neuroscience Centre, London, UK
| | - Luca Zampedri
- Leonard Wolfson Experimental Neuroscience Centre, London, UK
| | - John Dickson
- Institute of Nuclear Medicine, University College London Hospitals NHS Trust, London, UK
| | - Yazhou Li
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Iciar Aviles-Olmos
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | | | - Patricia Limousin
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Andrew J Lees
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Nigel H Greig
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Susan Tebbs
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK.
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Goldberg AJ, Zaidi R, Thomson C, Doré CJ, Skene SS, Cro S, Round J, Molloy A, Davies M, Karski M, Kim L, Cooke P. Total ankle replacement versus arthrodesis (TARVA): protocol for a multicentre randomised controlled trial. BMJ Open 2016; 6:e012716. [PMID: 27601503 PMCID: PMC5020669 DOI: 10.1136/bmjopen-2016-012716] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Total ankle replacement (TAR) or ankle arthrodesis (fusion) is the main surgical treatments for end-stage ankle osteoarthritis (OA). The popularity of ankle replacement is increasing while ankle fusion rates remain static. Both treatments have efficacy but to date all studies comparing the 2 have been observational without randomisation, and there are no published guidelines as to the most appropriate management. The TAR versus arthrodesis (TARVA) trial aims to compare the clinical and cost-effectiveness of TAR against ankle arthrodesis in the treatment of end-stage ankle OA in patients aged 50-85 years. METHODS AND ANALYSIS TARVA is a multicentre randomised controlled trial that will randomise 328 patients aged 50-85 years with end-stage ankle arthritis. The 2 arms of the study will be TAR or ankle arthrodesis with 164 patients in each group. Up to 16 UK centres will participate. Patients will have clinical assessments and complete questionnaires before their operation and at 6, 12, 26 and 52 weeks after surgery. The primary clinical outcome of the study is a validated patient-reported outcome measure, the Manchester Oxford foot questionnaire, captured preoperatively and 12 months after surgery. Secondary outcomes include quality-of-life scores, complications, revision, reoperation and a health economic analysis. ETHICS AND DISSEMINATION The protocol has been approved by the National Research Ethics Service Committee (London, Bloomsbury 14/LO/0807). This manuscript is based on V.5.0 of the protocol. The trial findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02128555.
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Affiliation(s)
- Andrew J Goldberg
- UCL Institute of Orthopaedics and Musculoskeletal Science (IOMS), Royal National Orthopaedic Hospital (RNOH), London, UK
| | - Razi Zaidi
- UCL Institute of Orthopaedics and Musculoskeletal Science (IOMS), Royal National Orthopaedic Hospital (RNOH), London, UK
| | - Claire Thomson
- Surgical Intervention Trials Unit, University of Oxford, Botnar Research Centre, Oxford, UK
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Simon S Skene
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Suzie Cro
- MRC Clinical Trials Unit, University College London, London, UK
| | - Jeff Round
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Andrew Molloy
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | | | - Louise Kim
- Joint Research and Enterprise Office, St George's University of London and St George's University Hospitals NHS Foundation Trust, London, UK
| | - Paul Cooke
- Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, UK
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Affiliation(s)
- Simon S Skene
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Catey Bunce
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Nick Freemantle
- Department of Primary Care and Population Health, University College London, London, UK
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, UK
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China L, Muirhead N, Skene SS, Shabir Z, PH De Maeyer R, Maini AAN, W Gilroy D, J O'Brien A. ATTIRE: Albumin To prevenT Infection in chronic liveR failurE: study protocol for a single-arm feasibility trial. BMJ Open 2016; 6:e010132. [PMID: 26810999 PMCID: PMC4735307 DOI: 10.1136/bmjopen-2015-010132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 02/07/2023] Open
Abstract
INTRODUCTION Circulating prostaglandin E2 levels are elevated in acutely decompensated cirrhosis and have been shown to contribute to immune suppression. Albumin binds and inactivates this hormone. Human albumin solution could thus be repurposed as an immune restorative drug in these patients.This feasibility study aims to determine whether it is possible and safe to restore serum albumin to >30 g/L and maintain it at this level in patients admitted with acute decompensated cirrhosis using repeated 20% human albumin infusions according to daily serum albumin levels. METHODS AND ANALYSIS Albumin To prevenT Infection in chronic liveR failurE (ATTIRE) stage 1 is a multicentre, open label dose feasibility trial. Patients with acutely decompensated cirrhosis admitted to hospital with a serum albumin of <30 g/L are eligible, subject to exclusion criteria. Daily intravenous human albumin solution will be infused, according to serum albumin levels, for up to 14 days or discharge in all patients. The primary end point is daily serum albumin levels for the duration of the treatment period and the secondary end point is plasma-induced macrophage dysfunction. The trial will recruit 80 patients. Outcomes will be used to assist with study design for an 866 patient randomised controlled trial at more than 30 sites across the UK. ETHICS AND DISSEMINATION Research ethics approval was given by the London-Brent research ethics committee (ref: 15/LO/0104). The clinical trials authorisation was issued by the medicines and healthcare products regulatory agency (ref: 20363/0350/001-0001). RESULTS Will be disseminated through peer reviewed journals and international conferences. Recruitment of the first participant occurred on 26/05/2015. TRIAL REGISTRATION NUMBER The trial is registered with the European Medicines Agency (EudraCT 2014-002300-24) and has been adopted by the NIHR (ISRCTN 14174793). This manuscript refers to V.4.0 of the protocol; Pre-results.
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Affiliation(s)
- Louise China
- Division of Medicine, University College London (UCL), London, UK
| | - Nicola Muirhead
- Comprehensive Clinical Trials Unit, University College London (UCL), London, UK
| | - Simon S Skene
- Comprehensive Clinical Trials Unit, University College London (UCL), London, UK
| | - Zainib Shabir
- Comprehensive Clinical Trials Unit, University College London (UCL), London, UK
| | | | | | - Derek W Gilroy
- Division of Medicine, University College London (UCL), London, UK
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Skene SS, Kenward MG. The analysis of very small samples of repeated measurements I: An adjusted sandwich estimator. Stat Med 2010; 29:2825-37. [DOI: 10.1002/sim.4073] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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