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Adams A, Gupta V, Mohsen W, Chapman TP, Subhaharan D, Kakkadasam Ramaswamy P, Kumar S, Kedia S, McGregor CG, Ambrose T, George BD, Palmer R, Brain O, Walsh A, Ahuja V, Travis SPL, Satsangi J. Early management of acute severe UC in the biologics era: development and international validation of a prognostic clinical index to predict steroid response. Gut 2023; 72:433-442. [PMID: 36171080 DOI: 10.1136/gutjnl-2022-327533] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [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] [Received: 04/05/2022] [Accepted: 08/27/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVES We aimed to determine whether changes in acute severe colitis (ASC) management have translated to improved outcomes and to develop a simple model predicting steroid non-response on admission. DESIGN Outcomes of 131 adult ASC admissions (117 patients) in Oxford, UK between 2015 and 2019 were compared with data from 1992 to 1993. All patients received standard treatment with intravenous corticosteroids and endoscopic disease activity scoring (Ulcerative Colitis Endoscopic Index of Severity (UCEIS)). Steroid non-response was defined as receiving medical rescue therapy or surgery. A predictive model developed in the Oxford cohort was validated in Australia and India (Gold Coast University Hospital 2015-2020, n=110; All India Institute of Medical Sciences, New Delhi 2018-2020, n=62). RESULTS In the 2015-2019 Oxford cohort, 15% required colectomy during admission vs 29% in 1992-1993 (p=0.033), while 71 (54%) patients received medical rescue therapy (27% ciclosporin, 27% anti-tumour necrosis factor, compared with 27% ciclosporin in 1992-1993 (p=0.0015). Admission C reactive protein (CRP) (false discovery rate, p=0.00066), albumin (0.0066) and UCEIS scores (0.015) predicted steroid non-response. A four-point model was developed involving CRP of ≥100 mg/L (one point), albumin of ≤25 g/L (one point), and UCEIS score of ≥4 (1 point) or ≥7 (2 points). Patients scoring 0, 1, 2, 3 and 4 in the validation cohorts had steroid response rates of 100, 75.0%, 54.9%, 18.2% and 0%, respectively. Scoring of ≥3 was 84% (95% CI 0.70 to 0.98) predictive of steroid failure (OR 11.9, 95% CI 10.8 to 13.0). Colectomy rates in the validation cohorts were were 8%-11%. CONCLUSIONS Emergency colectomy rates for ASC have halved in 25 years to 8%-15% worldwide. Patients who will not respond to corticosteroids are readily identified on admission and may be prioritised for early intensification of therapy.
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Affiliation(s)
- Alex Adams
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Vipin Gupta
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,Department of Gastroenterology, North Bristol NHS Trust, Bristol, UK
| | - Waled Mohsen
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,Digestive Diseases Unit, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Thomas P Chapman
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,Department of Gastroenterology, St Richard's and Worthing Hospitals, University Hospitals Sussex NHS Foundation Trust, West Sussex, UK
| | - Deloshaan Subhaharan
- Digestive Diseases Unit, Gold Coast University Hospital, Southport, Queensland, Australia
| | | | - Sudheer Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Tim Ambrose
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Bruce D George
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Rebecca Palmer
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Oliver Brain
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Alissa Walsh
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Simon P L Travis
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Jack Satsangi
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
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Wong D, Matini L, Kormilitzin A, Kantschuster R, Simadibrata DM, Lyden S, Wilson J, Brain OA, Palmer R, Ambrose T, Satsangi J, South M, Geddes J, Bodger K, Travis SPL, Walsh A. Patient-reported Outcomes: the ICHOM Standard Set for Inflammatory Bowel Disease in Real-life Practice Helps Quantify Deficits in Current Care. J Crohns Colitis 2022; 16:1874-1881. [PMID: 35868223 PMCID: PMC9721458 DOI: 10.1093/ecco-jcc/jjac099] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patient-reported outcome measures [PROMs] are key to documenting outcomes that matter most to patients and are increasingly important to commissioners of health care seeking value. We report the first series of the ICHOM Standard Set for Inflammatory Bowel Disease [IBD]. METHODS Patients treated for ulcerative colitis [UC] or Crohn's disease [CD] in our centre were offered enrolment into the web-based TrueColours-IBD programme. Through this programme, e-mail prompts linking to validated questionnaires were sent for symptoms, quality of life, and ICHOM IBD outcomes. RESULTS The first 1299 consecutive patients enrolled [779 UC, 520 CD] were studied with median 270 days of follow-up (interquartile range [IQR] 116, 504). 671 [52%] were female, mean age 42 years (standard deviation [sd] 16), mean body mass index [BMI] 26 [sd 5.3]. At registration, 483 [37%] were using advanced therapies. Median adherence to fortnightly quality of life reporting and quarterly outcomes was 100% [IQR 48, 100%] and 100% [IQR 75, 100%], respectively. In the previous 12 months, prednisolone use was reported by 229 [29%] patients with UC vs 81 [16%] with CD, p <0.001; 202 [16%] for <3 months; and 108 [8%] for >3 months. An IBD-related intervention was reported by 174 [13%] patients, and 80 [6%] reported an unplanned hospital admission. There were high rates of fatigue [50%] and mood disturbance [23%]. CONCLUSIONS Outcomes reported by patients illustrate the scale of the therapeutic deficit in current care. Proof of principle is demonstrated that PROM data can be collected continuously with little burden on health care professionals. This may become a metric for quality improvement programmes or to compare outcomes.
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Affiliation(s)
- Darren Wong
- Corresponding author: Dr Alissa Walsh, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford OX3 9DU, UK. E-mail:
| | - Lawrence Matini
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | | | - Ramona Kantschuster
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Daniel Martin Simadibrata
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK,Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Sara Lyden
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Jean Wilson
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Oliver A Brain
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Rebecca Palmer
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Tim Ambrose
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Jack Satsangi
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Matthew South
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Keith Bodger
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Alissa Walsh
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
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McGregor CG, Adams A, Sadler R, Arancibia-Cárcamo CV, Palmer R, Ambrose T, Brain O, Walsh A, Klenerman P, Travis SP, Croft NM, Lindsay JO, Satsangi J. Maintenance therapy with infliximab or vedolizumab in IBD is not associated with increased SARS-CoV-2 seroprevalence: UK experience in the 2020 pandemic. Gut 2021; 70:2398-2400. [PMID: 33579788 DOI: 10.1136/gutjnl-2021-324116] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Colleen Gc McGregor
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Alex Adams
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Ross Sadler
- Department of Laboratory Immunology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Carolina V Arancibia-Cárcamo
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Rebecca Palmer
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Tim Ambrose
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Oliver Brain
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Alissa Walsh
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Paul Klenerman
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Simon Pl Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Nicholas M Croft
- Centre for Immunobiology, Blizard Institute, Queen Mary University of London, London, UK.,Departments of Gastroenterology and Paediatric Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - James O Lindsay
- Centre for Immunobiology, Blizard Institute, Queen Mary University of London, London, UK.,Departments of Gastroenterology and Paediatric Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Jack Satsangi
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
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Allan PJ, Ambrose T, Mountford C, Bond A, Donnellan C, Boyle R, Calvert C, Cernat E, Clarke E, Cooper SC, Donnelly S, Evans B, Glynn M, Hewett R, Holohan AS, Leitch EF, Louis-Auguste J, Mehta S, Naik S, Nightingale J, Rafferty G, Rodrigues A, Sharkey L, Small M, Teubner A, Urs A, Wyer N, Lal S. COVID-19 infection in patients with intestinal failure: UK experience. JPEN J Parenter Enteral Nutr 2021; 45:1369-1375. [PMID: 33586170 PMCID: PMC8013499 DOI: 10.1002/jpen.2087] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The direct effect of the coronavirus disease 2019 (COVID-19) pandemic on patients with intestinal failure (IF) has not been described. METHODS We conducted a nationwide study of UK IF centers to evaluate the infection rates, presentations, and outcomes in patients with types 2 and 3 IF. RESULTS A total of 45 patients with IF contracted COVID-19 between March and August 2020; this included 26 of 2191 (1.2%) home parenteral nutrition (HPN)-dependent adults and 19 of 298 (6.4%) adults hospitalized with type 2 IF. The proportion of patients receiving nursing care for HPN administration was higher in those with community-acquired COVID-19 (66.7%) than the proportion in the entire HPN cohort (26.1%; P < .01). Two HPN-dependent and 1 hospitalized patient with type 2 IF died as a direct consequence of the virus (6.7% of 45 patients with types 2 or 3 infected). CONCLUSION This is the first study to describe the outcomes of COVID-19 in a large cohort of patients requiring long-term PN. Methods to reduce hospital and community nosocomial spread would likely be beneficial.
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Affiliation(s)
- P J Allan
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - T Ambrose
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C Mountford
- Department of Gastroenterology, Freeman Hospital, Newcastle, UK
| | - A Bond
- Department of Gastroenterology, Royal Liverpool and Broadgreen Hospitals, Liverpool, UK
| | - C Donnellan
- St James' and Leeds Gastroenterology Institute, St James' Hospital, Leeds, UK
| | - R Boyle
- Department of Biochemistry, Aberdeen Royal Infirmary, Aberdeen, UK
| | - C Calvert
- Department of Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK
| | - E Cernat
- Department of Paediatric Gastroenterology, Leeds General Infirmary, Leeds, UK
| | - E Clarke
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - S C Cooper
- GI Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Donnelly
- Leonard Jones' Intestinal Rehabilitation Unit, St Mark's Hospital, Harrow, UK
| | - B Evans
- Department of Gastroenterology, Bristol Royal Infirmary, Bristol, UK
| | - M Glynn
- Centre for Digestive Diseases, Royal London Hospital, London, UK
| | - R Hewett
- Department of Gastroenterology, University of Wales Hospital, Cardiff, UK
| | - A S Holohan
- Nutrition, Leicester Royal Infirmary, Leicester, UK
| | - E F Leitch
- Intestinal Failure Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | | | - S Mehta
- Intestinal Failure Unit, University College London Hospitals, London, UK
| | - S Naik
- Department of Paediatric Gastroenterology, Royal London Children's Hospital, London, UK
| | | | - G Rafferty
- Department of Gastroenterology, Belfast City Hospital, Belfast, UK
| | - A Rodrigues
- Department of Paediatric Gastroenterology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - L Sharkey
- Intestinal Failure and Transplant, Cambridge University Hospitals, Cambridge, UK
| | - M Small
- Leonard Jones' Intestinal Rehabilitation Unit, St Mark's Hospital, Harrow, UK
| | - A Teubner
- Intestinal Failure Unit, Salford Royal Hospital, Salford, UK
| | - A Urs
- Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, UK
| | - N Wyer
- Intestinal Failure and Nutrition Support, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - S Lal
- Intestinal Failure Unit, Salford Royal Hospital, Salford, UK.,Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and Manchester Academic Health Sciences Centre, Manchester, UK
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5
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Ambrose T, De Silva A, Naghibi M, Saunders J, Smith TR, Coleman RL, Stroud M. Refeeding risks in patients requiring intravenous nutrition support: Results of a two-centre, prospective, double-blind, randomised controlled trial. Clin Nutr ESPEN 2021; 41:143-152. [PMID: 33487258 DOI: 10.1016/j.clnesp.2020.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND/AIMS Refeeding syndrome can result following excessive feeding of malnourished patients. The syndrome remains poorly defined but encompasses a range of adverse effects including electrolyte shifts, hyperglycaemia and other less well-defined phenomena. There are additional risks of underfeeding malnourished individuals. Studies of refeeding syndrome have generally focussed on critical care environments or patients with anorexia nervosa. Here we have conducted a two-centre, prospective, double-blind, randomised controlled trial amongst all patients referred to hospital nutrition support teams for intravenous nutrition support. We sought to determine whether electrolyte and other abnormalities suggestive of refeeding syndrome risk varied depending on initial rate of intravenous feeding. METHODS Patients at moderate or high risk of refeeding syndrome, as defined by United Kingdom National Institute of Health and Care Excellence guidelines, were screened for inclusion. Patients were randomised to receive either high (30 kcal/kg/day, 0.25 gN/kg/day) or low (15 kcal/day, 0.125 gN/kg/day) rate feeding for the first 48 h prior to escalation to standard parenteral nutrition regimens. The primary outcome was rates of potential refeeding risks within the first 7 days as defined by electrolyte imbalance or hyperglycaemia requiring insulin. Secondary outcomes included effects on QTc interval, infections and length of hospital stay. Statistical analysis was performed with χ2 or Wilcoxon rank sum tests and all analysis was intention-to-treat. Problems with study recruitment led to premature termination of the trial. Registered on the EU Clinical Trials Register (EudraCT number 2007-005547-17). RESULTS 534 patients were screened and 104 randomised to either high or low rate feeding based on risk of refeeding syndrome. Seven patients were withdrawn prior to collection of baseline demographics and were excluded from analysis. 48 patients were analysed for the primary outcome with potential refeeding risks identified in 46%. No differences in risks were seen between high and low rate feeding (p > 0.99) or high and moderate risk feeding (p = 0.68). There were no differences in QTc abnormalities, infection rates, or hospital length of stay between groups. CONCLUSIONS In this randomised trial of rates of refeeding risk, in patients pre-stratified as being at high or moderate risk, we found no evidence of increased refeeding related disturbances in those commenced on high rate feeding compared to low rate. No differences were seen in secondary endpoints including cardiac rhythm analysis, infections or length of stay. Our study reflects real world experience of patients referred for nutrition support and highlights challenges encountered when conducting clinical nutrition research.
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Affiliation(s)
- Tim Ambrose
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, United Kingdom
| | - Aminda De Silva
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, United Kingdom
| | - Mani Naghibi
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, United Kingdom
| | - John Saunders
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, United Kingdom
| | - Trevor R Smith
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, United Kingdom
| | - Ruth L Coleman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Oxford, OX3 7LJ, United Kingdom
| | - Mike Stroud
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, United Kingdom.
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6
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FitzPatrick MEB, Provine NM, Garner LC, Powell K, Amini A, Irwin SL, Ferry H, Ambrose T, Friend P, Vrakas G, Reddy S, Soilleux E, Klenerman P, Allan PJ. Human intestinal tissue-resident memory T cells comprise transcriptionally and functionally distinct subsets. Cell Rep 2021; 34:108661. [PMID: 33472060 PMCID: PMC7816164 DOI: 10.1016/j.celrep.2020.108661] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 10/14/2020] [Accepted: 12/22/2020] [Indexed: 01/07/2023] Open
Abstract
Tissue-resident memory T (TRM) cells provide key adaptive immune responses in infection, cancer, and autoimmunity. However, transcriptional heterogeneity of human intestinal TRM cells remains undefined. Here, we investigate transcriptional and functional heterogeneity of human TRM cells through study of donor-derived TRM cells from intestinal transplant recipients. Single-cell transcriptional profiling identifies two transcriptional states of CD8+ TRM cells, delineated by ITGAE and ITGB2 expression. We define a transcriptional signature discriminating these populations, including differential expression of cytotoxicity- and residency-associated genes. Flow cytometry of recipient-derived cells infiltrating the graft, and lymphocytes from healthy gut, confirm these CD8+ TRM phenotypes. CD8+ CD69+CD103+ TRM cells produce interleukin-2 (IL-2) and demonstrate greater polyfunctional cytokine production, whereas β2-integrin+CD69+CD103− TRM cells have higher granzyme expression. Analysis of intestinal CD4+ T cells identifies several parallels, including a β2-integrin+ population. Together, these results describe the transcriptional, phenotypic, and functional heterogeneity of human intestinal CD4+ and CD8+ TRM cells. Human intestinal transplants were used to identify bona fide TRM cells Single-cell RNA sequencing identifies two distinct CD8+ TRM subsets CD103+CD69+ and CD103−CD69+ TRM cell subsets show distinct localization and function β2-integrin is highly expressed on CD103− TRM cells
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Affiliation(s)
- Michael E B FitzPatrick
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Nicholas M Provine
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Lucy C Garner
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Kate Powell
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford OX1 3SY, UK
| | - Ali Amini
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Sophie L Irwin
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Helen Ferry
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Tim Ambrose
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Peter Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, UK; Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE, UK
| | - Georgios Vrakas
- Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE, UK
| | - Srikanth Reddy
- Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE, UK
| | - Elizabeth Soilleux
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, UK
| | - Paul Klenerman
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK; Peter Medawar Building for Pathogen Research, University of Oxford, Oxford OX1 3SY, UK; NIHR Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK.
| | - Philip J Allan
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK; Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE, UK; NIHR Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
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7
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Ambrose T, Travis SPL, Allan PJ. Letter to the editor-Reply-Intestinal transplantation and quality of life. Clin Nutr 2020; 40:332-333. [PMID: 33248873 DOI: 10.1016/j.clnu.2020.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Tim Ambrose
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
| | - Simon P L Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Philip J Allan
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom; Oxford Transplant Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Oxford, OX3 7LE, United Kingdom
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8
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Ambrose T, Holdaway L, Smith A, Howe H, Vokes L, Vrakas G, Reddy S, Giele H, Travis SP, Friend PJ, Allan PJ. The impact of intestinal transplantation on quality of life. Clin Nutr 2020; 39:1958-1967. [DOI: 10.1016/j.clnu.2019.08.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 08/24/2019] [Accepted: 08/26/2019] [Indexed: 11/30/2022]
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Abstract
Cannabis sativa and its extracts have been used for centuries, both medicinally and recreationally. There is accumulating evidence that exogenous cannabis and related cannabinoids improve symptoms associated with inflammatory bowel disease [IBD], such as pain, loss of appetite, and diarrhoea. In vivo, exocannabinoids have been demonstrated to improve colitis, mainly in chemical models. Exocannabinoids signal through the endocannabinoid system, an increasingly understood network of endogenous lipid ligands and their receptors, together with a number of synthetic and degradative enzymes and the resulting products. Modulating the endocannabinoid system using pharmacological receptor agonists, genetic knockout models, or inhibition of degradative enzymes have largely shown improvements in colitis in vivo. Despite these promising experimental results, this has not translated into meaningful benefits for human IBD in the few clinical trials which have been conducted to date, the largest study being limited by poor medication tolerance due to the Δ9-tetrahydrocannabinol component. This review article synthesises the current literature surrounding the modulation of the endocannabinoid system and administration of exocannabinoids in experimental and human IBD. Findings of clinical surveys and studies of cannabis use in IBD are summarised. Discrepancies in the literature are highlighted together with identifying novel areas of interest.
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Affiliation(s)
- Tim Ambrose
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK,MRC Human Immunology Unit, John Radcliffe Hospital, Oxford, UK,Corresponding author: Dr Tim Ambrose, BSc (Hons), MBChB, MRCP (UK) (Gastroenterology), c/o Prof. Alison Simmons, MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Headley Way, Oxford OX3 9DS, UK. Tel.: 01865 222628;
| | - Alison Simmons
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK,MRC Human Immunology Unit, John Radcliffe Hospital, Oxford, UK
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Aulicino A, Rue-Albrecht KC, Preciado-Llanes L, Napolitani G, Ashley N, Cribbs A, Koth J, Lagerholm BC, Ambrose T, Gordon MA, Sims D, Simmons A. Invasive Salmonella exploits divergent immune evasion strategies in infected and bystander dendritic cell subsets. Nat Commun 2018; 9:4883. [PMID: 30451854 PMCID: PMC6242960 DOI: 10.1038/s41467-018-07329-0] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 10/25/2018] [Indexed: 01/06/2023] Open
Abstract
Non-typhoidal Salmonella (NTS) are highly prevalent food-borne pathogens. Recently, a highly invasive, multi-drug resistant S. Typhimurium, ST313, emerged as a major cause of bacteraemia in children and immunosuppressed adults, however the pathogenic mechanisms remain unclear. Here, we utilize invasive and non-invasive Salmonella strains combined with single-cell RNA-sequencing to study the transcriptome of individual infected and bystander monocyte-derived dendritic cells (MoDCs) implicated in disseminating invasive ST313. Compared with non-invasive Salmonella, ST313 directs a highly heterogeneous innate immune response. Bystander MoDCs exhibit a hyper-activated profile potentially diverting adaptive immunity away from infected cells. MoDCs harbouring invasive Salmonella display higher expression of IL10 and MARCH1 concomitant with lower expression of CD83 to evade adaptive immune detection. Finally, we demonstrate how these mechanisms conjointly restrain MoDC-mediated activation of Salmonella-specific CD4+ T cell clones. Here, we show how invasive ST313 exploits discrete evasion strategies within infected and bystander MoDCs to mediate its dissemination in vivo.
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Affiliation(s)
- Anna Aulicino
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK
- Translational Gastroenterology Unit, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, UK
| | - Kevin C Rue-Albrecht
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, OX3 7FY, UK
| | - Lorena Preciado-Llanes
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK
- Translational Gastroenterology Unit, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, UK
| | - Giorgio Napolitani
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK
| | - Neil Ashley
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford and BRC Blood Theme, NIHR Oxford Biomedical Centre, Oxford, OX3 9DS, UK
| | - Adam Cribbs
- MRC WIMM Centre for Computational Biology, MRC Weatherall Institute of Molecular medicine, University of Oxford, Oxford, OX3 9DS, UK
| | - Jana Koth
- MRC Human Immunology Unit and Wolfson Imaging Centre, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK
| | - B Christoffer Lagerholm
- MRC Human Immunology Unit and Wolfson Imaging Centre, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK
| | - Tim Ambrose
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK
- Translational Gastroenterology Unit, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, UK
| | - Melita A Gordon
- Institute of Infection and Global Health, University of Liverpool, 8 W Derby St, Liverpool, L7 3EA, UK
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - David Sims
- MRC WIMM Centre for Computational Biology, MRC Weatherall Institute of Molecular medicine, University of Oxford, Oxford, OX3 9DS, UK
| | - Alison Simmons
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK.
- Translational Gastroenterology Unit, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, UK.
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Louis-Auguste JR, Micallef C, Ambrose T, Upponi S, Butler AJ, Massey D, Middleton SJ, Russell N, Rutter CS, Sharkey LM, Woodward J, Gkrania-Klotsas E, Enoch DA. Fatal breakthrough mucormycosis in a multivisceral transplant patient receiving micafungin: Case report and literature review. IDCases 2018; 12:76-79. [PMID: 29942755 PMCID: PMC6010962 DOI: 10.1016/j.idcr.2018.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Antifungal agents are routinely used in the post-transplant setting for both prophylaxis and treatment of presumed and proven fungal infections. Micafungin is an echinocandin-class antifungal with broad antifungal cover and favorable side effect profile but, notably, it has no activity against molds of the order Mucorales. Presentation of case A 47-year-old woman underwent multivisceral transplantation for intestinal failure-associated liver disease. She had a prolonged post-operative recovery complicated by invasive candidiasis and developed an intolerance to liposomal amphotericin B. In view of her immunosuppression, she was commenced on micafungin as prophylaxis to prevent invasive fungal infection. However, she developed acute graft versus host disease with bone marrow failure complicated by disseminated mucormycosis which was only diagnosed post mortem. Discussion Non-Aspergillus breakthrough mold infections with micafungin therapy are rare with only eight other cases having been described in the literature. Breakthrough infections have occurred within one week of starting micafungin. Diagnosis is problematic and requires a high degree of clinical suspicion and microscopic/histological examination of an involved site. The management of these aggressive infections involves extensive debridement and appropriate antifungal cover. Conclusion A high level of suspicion of invasive fungal infection is required at all times in immunosuppressed patients, even those receiving antifungal prophylaxis. Early biopsy is required. Even with early recognition and aggressive treatment of these infections, prognosis is poor.
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Affiliation(s)
- John R Louis-Auguste
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christianne Micallef
- Clinical Microbiology & Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tim Ambrose
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sara Upponi
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew J Butler
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Dunecan Massey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen J Middleton
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil Russell
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charlotte S Rutter
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Lisa M Sharkey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jeremy Woodward
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David A Enoch
- Clinical Microbiology & Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Abstract
Activation of the innate immune system through pattern-recognition receptor (PRR) signaling plays a pivotal role in the early induction of host defense following exposure to pathogens. Loss of intestinal innate immune regulation leading aberrant immune responses has been implicated in the pathogenesis of inflammatory bowel disease (IBD). The precise role of PRRs in gut inflammation is not well understood, but considering their role as bacterial sensors and their genetic association with IBD, they likely contribute to dysregulated immune responses to the commensal microbiota. The purpose of this review is to evaluate the emerging functions of PRRs including their functional cross-talk, how they respond to mitochondrial damage, induce mitophagy or autophagy, and influence adaptive immune responses by interacting with the antigen presentation machinery. The review also summarizes some of the recent attempts to harness these pathways for therapeutic approaches in intestinal inflammation.
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Affiliation(s)
- Daniele Corridoni
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.,Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Thomas Chapman
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.,Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Tim Ambrose
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.,Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Alison Simmons
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.,Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
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13
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Topan R, Ambrose T, Small M, Lightman E, Nightingale J, Gabe SM. Spinal Infections Among Patients With Long-Term Central Venous Catheters for Home Parenteral Nutrition: A Descriptive Case Series. Nutr Clin Pract 2017; 32:133-138. [PMID: 30865344 DOI: 10.1177/0884533616657545] [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: 11/15/2022] Open
Abstract
Spinal infections are a rare yet serious metastatic complication of bacteremia among patients with long-term central venous catheters (CVCs) for which clinicians must remain vigilant. We performed a retrospective review of all cases of spinal infection occurring in the context of a CVC for long-term parenteral nutrition (PN) managed in our department between January 2010 and October 2013, a cohort of 310 patients over this time period. Six patients were identified (mean age, 65 years; 5 male). One hundred percent of patients presented with spinal pain (5/6 cervical, 1/6 thoracic). Organisms were cultured from the CVC in 5 of 6 patients. In all cases, the white blood cell count was normal, and in 5 of 6, C-reactive protein was normal. All diagnoses were confirmed on magnetic resonance imaging (MRI), and in 3 of 6 cases, an MRI was repeated (on the advice of neurosurgical colleagues) to confirm resolution of changes after a period of antimicrobial therapy. There was no clear correlation between duration of PN or number of days following CVC insertion and onset of infection. The CVC was replaced in 4 of 6 patients at the time of diagnosis, delayed removal in 1 of 6, and salvaged in the remaining case. Although rare, a high index of suspicion is needed in patients receiving long-term PN who present with spinal pain. Peripheral inflammatory markers may not be elevated. MRI should be performed and patients should be treated with antibiotics alongside involvement of local microbiology and neurosurgical teams. Multidisciplinary discussion on CVC salvage in these cases is important, especially in cases of challenging vascular anatomy.
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Affiliation(s)
- Rabia Topan
- Lennard Jones Intestinal Failure Unit, St Mark's Hospital, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Tim Ambrose
- Lennard Jones Intestinal Failure Unit, St Mark's Hospital, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Mia Small
- Lennard Jones Intestinal Failure Unit, St Mark's Hospital, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Elewys Lightman
- Lennard Jones Intestinal Failure Unit, St Mark's Hospital, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Jeremy Nightingale
- Lennard Jones Intestinal Failure Unit, St Mark's Hospital, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Simon M Gabe
- Lennard Jones Intestinal Failure Unit, St Mark's Hospital, London North West Healthcare NHS Trust, Harrow, London, UK
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14
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Ambrose T, Sharkey LM, Louis-Auguste J, Rutter CS, Duncan S, English S, Gkrania-Klotsas E, Carmichael A, Woodward JM, Russell N, Massey D, Butler A, Middleton S. Cytomegalovirus Infection and Rates of Antiviral Resistance Following Intestinal and Multivisceral Transplantation. Transplant Proc 2017; 48:492-6. [PMID: 27109985 DOI: 10.1016/j.transproceed.2015.09.070] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/03/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) disease is a common and clinically significant complication following intestinal or multivisceral transplantation. CMV disease is more common in cases of serologic mismatch between donor and recipient. Though in some cases it may be asymptomatic, in the immunosuppressed population it often manifests with evidence of systemic infection or end-organ disease. METHODS We conducted a retrospective review of all patients undergoing intestinal or multivisceral transplantation over 8 years at our institution. RESULTS Forty-eight transplantations were performed, with 40% of the patients (19/48) having ≥1 episode of CMV viremia, which rose to 90% in the "donor-positive, recipient-negative" (DPRN) serologic mismatch group. The median time to 1st episode following transplantation was 22.3 weeks (range, 1-78) and median duration of each episode was 4.9 weeks (range, 1.6-37.4). Six of the 19 viremic patients (31.6%) developed virologic resistance with 4 of these occurring in the DPRN group. Four of the 6 patients with drug-resistant CMV died with CMV viremia. All patients with drug resistance acquired ganciclovir resistance; these patients were more challenging to manage with second-line toxicity-limited treatments, including foscarnet, cidofovir, and leflunomide. CMV immunoglobulin has been used and we briefly discuss the use of CMV-specific adoptive T-lymphocyte transfer in the management of 1 case. CONCLUSIONS Post-transplantation CMV disease continues to be challenging to manage, and there is little consensus on optimal management strategies in this patient group, with a significant requirement for novel therapies; these may be pharmacologic or cell based. Extensive multidisciplinary discussion is important for most cases, but particularly for those patients who acquire virologic resistance.
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Affiliation(s)
- T Ambrose
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - L M Sharkey
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - J Louis-Auguste
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - C S Rutter
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - S Duncan
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - S English
- Department of Clinical Virology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - E Gkrania-Klotsas
- Department of Infectious Diseases, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - A Carmichael
- Department of Infectious Diseases, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - J M Woodward
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - N Russell
- Department of Transplant Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - D Massey
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - A Butler
- Department of Transplant Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - S Middleton
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, United Kingdom.
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15
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Diao Y, Greatorex J, Zhang H, English S, White H, Brugger K, Ambrose T, Butler A, Russell N, Massey D, Middleton S, Gkrania-Klotsas E. Earlier detection of drug resistant mutations in small bowel/multivisceral transplant recipients with CMV infection using next generation sequencing. J Infect 2015. [DOI: 10.1016/j.jinf.2015.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Ambrose T, Sharkey L, Louis-Auguste J, Butler A, Massey D, Russell N, Pursglove S, Middleton SJ. Stomal Cytomegalovirus Infection Following Intestinal Transplant. Am J Gastroenterol 2015; 110:1534. [PMID: 26618415 DOI: 10.1038/ajg.2015.73] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ambrose T, Cullen S, Baker G, Smith M, Elia M, Leach R. Obesity: a window of opportunity to intervene? Characteristics and management of morbidly obese adult inpatients in three trusts in Southern England. Clin Med (Lond) 2013; 13:472-6. [PMID: 24115704 PMCID: PMC4953798 DOI: 10.7861/clinmedicine.13-5-472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Obesity affects 22% of men and 24% of women over the age of 16 years in the general population of the UK and is associated with multiple comorbidities. Little is known about the magnitude of the obesity problem among hospitalised adults and, although significant focus has been given to the identification and treatment of the malnourished inpatient, it is not known to what extent obese inpatients are equally -targeted. National guidelines for consideration of bariatric surgery exist, but it is not known to what extent potentially eligible individuals are referred. This multi-centre study -demonstrates a significant burden of obesity (defined as body mass index [BMI] ≥30 kg/m(2)) among those in hospital, affecting 22% of patients. This was more marked among orthopaedic patients and all-comers to intensive care units than on medical or surgical wards. Of those with BMI ≥35 kg/m(2), only 21% had been reviewed by dietetics and only 10% of patients who were potentially eligible for bariatric surgery had been referred to bariatric services. This study shows that there is an opportunity to recognise obesity and intervene in its management during hospital admission.
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Affiliation(s)
- Tim Ambrose
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Sue Cullen
- Department of Gastroenterology, Wycombe Hospital, High Wycombe, UK
| | - Gerard Baker
- Department of Gastroenterology, Wycombe Hospital, High Wycombe, UK
| | - Melissa Smith
- Departments of Gastroenterology and Respiratory Medicine, St Thomas’ Hospital, London, UK
| | - Marinos Elia
- Institute of Human Nutrition and Nutrition Biochemical Research Centre, University Hospital Southampton, Southampton, UK
| | - Richard Leach
- Departments of Gastroenterology and Respiratory Medicine, St Thomas’ Hospital, London, UK
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18
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Ambrose T, Barry B, Ellis AJ. Cut loose and cast adrift. Gastroenterology 2013; 145:e4-e5. [PMID: 23727485 DOI: 10.1053/j.gastro.2013.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 03/11/2013] [Indexed: 12/02/2022]
Affiliation(s)
- Tim Ambrose
- Department of Gastroenterology, Horton General Hospital, Oxford University Hospitals NHS Trust, Banbury, United Kingdom
| | - Brendan Barry
- Department of Radiology, Horton General Hospital, Oxford University Hospitals NHS Trust, Banbury, United Kingdom
| | - Antony J Ellis
- Department of Gastroenterology, Horton General Hospital, Oxford University Hospitals NHS Trust, Banbury, United Kingdom
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Ambrose T, Stephenson TJ, Booth J, Chandra N. Case report: recurrent acute pancreatitis secondary to papillary somatostatinoma--a new association. Pancreatology 2013; 13:186-8. [PMID: 23561978 DOI: 10.1016/j.pan.2013.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 01/27/2013] [Accepted: 01/31/2013] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis may rarely be caused by papillary mass lesions such as adenocarcinomas and neuroendocrine tumours. Occasionally these papillary lesions may cause recurrent episodes of acute pancreatitis and patients presenting in this way require further pancreatic investigation. We believe this to be the first reported case of a duodenal papillary somatostatinoma causing recurrent acute pancreatitis. The patient was investigated with multiple imaging modalities, both at endoscopy and with more traditional radiology, and treated with resection by Whipple's pancreaticoduodenectomy. If diagnosed early in the absence of distant metastases the prognosis of papillary somatostatinoma with tumour resection is excellent.
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Affiliation(s)
- Tim Ambrose
- Department of Gastroenterology, Royal Berkshire Hospital, London Road, Reading RG1 5AN, United Kingdom
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20
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Affiliation(s)
- Tim Ambrose
- Department of Gastroenterology, Royal Berkshire Hospital, Reading, UK
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Snapp M, Ambrose T, Kremens D, Marmura M, Rakocevic G. Evolving Sjogren to POEMS Neuropathy Associated with a Large B-Cell Lymphoma: A Case Report (P07.147). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p07.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ambrose T, Rajendran N, Macfaul G. A rare cause of haematemesis and chest pain. Br J Hosp Med (Lond) 2011; 72:592. [PMID: 22041732 DOI: 10.12968/hmed.2011.72.10.592] [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: 11/11/2022]
Abstract
This article discusses an elderly woman presenting with haematemesis and chest pain who underwent urgent oesophago-gastroduodenoscopy. This revealed a large dissecting intramural oesophageal haematoma, initially mistaken for a varix. This is a rare cause of haematemesis and chest pain but has characteristic endoscopic findings. It is a benign condition that may be managed conservatively and both clinicians and endoscopists should be aware of its classical presentation. Misdiagnosis of the chest pain as cardiac ischaemia may have an adverse outcome if antiplatelet or anticoagulation therapy is commenced. Follow up endoscopy a week later showed complete resolution of the lesion leaving a linear mucosal defect.
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Affiliation(s)
- Tim Ambrose
- Department of Gastroenterology, Milton Keynes General Hospital.
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Chakkarava V, Ambrose T, Vincent S, Arunachala R, Paulraj M, Ignacimuth S, Annadurai G. Bioefficacy of Azadirachta indica (A. Juss) and Datura metel (Linn.) Leaves Extracts in Controlling Culex quinquefasciatus (Diptera: Culicidae). ACTA ACUST UNITED AC 2011. [DOI: 10.3923/je.2011.191.197] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kalaitzakis E, Ambrose T, Phillips-Hughes J, Collier J, Chapman RW. Management of patients with biliary sphincter of Oddi disorder without sphincter of Oddi manometry. BMC Gastroenterol 2010; 10:124. [PMID: 20969779 PMCID: PMC2975654 DOI: 10.1186/1471-230x-10-124] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 10/22/2010] [Indexed: 12/13/2022] Open
Abstract
Background The paucity of controlled data for the treatment of most biliary sphincter of Oddi disorder (SOD) types and the incomplete response to therapy seen in clinical practice and several trials has generated controversy as to the best course of management of these patients. In this observational study we aimed to assess the outcome of patients with biliary SOD managed without sphincter of Oddi manometry. Methods Fifty-nine patients with biliary SOD (14% type I, 51% type II, 35% type III) were prospectively enrolled. All patients with a dilated common bile duct were offered endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy whereas all others were offered medical treatment alone. Patients were followed up for a median of 15 months and were assessed clinically for response to treatment. Results At follow-up 15.3% of patients reported complete symptom resolution, 59.3% improvement, 22% unchanged symptoms, and 3.4% deterioration. Fifty-one percent experienced symptom resolution/improvement on medical treatment only, 12% after sphincterotomy, and 10% after both medical treatment/sphincterotomy. Twenty percent experienced at least one recurrence of symptoms after initial response to medical and/or endoscopic treatment. Fifty ERCP procedures were performed in 24 patients with an 18% complication rate (16% post-ERCP pancreatitis). The majority of complications occurred in the first ERCP these patients had. Most complications were mild and treated conservatively. Age, gender, comorbidity, SOD type, dilated common bile duct, presence of intact gallbladder, or opiate use were not related to the effect of treatment at the end of follow-up (p > 0.05 for all). Conclusions Patients with biliary SOD may be managed with a combination of endoscopic sphincterotomy (performed in those with dilated common bile duct) and medical therapy without manometry. The results of this approach with regards to symptomatic relief and ERCP complication rate are comparable to those previously published in the literature in cohorts of patients assessed by manometry.
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Abstract
Hydrocephalus is a life-threatening condition presenting with a wide range of symptoms to a variety of specialties. Resulting delays in diagnosis can be hazardous. Doctors in all specialties should be familiar with the protean presentations of hydrocephalus.
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Affiliation(s)
- Tim Ambrose
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh
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26
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Athikesavan S, Vincent S, Ambrose T, Velmurugan B. Nickel induced histopathological changes in the different tissues of freshwater fish, Hypophthalmichthys molitrix (Valenciennes). J Environ Biol 2006; 27:391-5. [PMID: 17436530] [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] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Nickel chloride, heavy metal widely used in industries was investigated in the present study for histopathological studies in silver carp (Hypophthalmichthys molitrix). Fish were exposed for 10, 20 and 30 days in sublethal concentration of nickel 5.7 mg/l. The histopathological changes were studied in the gill, liver, intestine and kidney of the nickel treated freshwater fish H. molitrix. The nickel showed a tissue specific alteration in the tissues. Mucus proliferation, fusion of the gill lamellae and hypertrophy of gill tissues were observed. Lack of normal palisade arrangement was followed by necrosis in hepatocytes. Degeneration of blood vessels, vacuolation, hypertrophy, pyknotic nuclei and lesion were observed in liver tissues. Degeneration of tubular cells, hyperplasia was observed in kidney tissues.
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Affiliation(s)
- S Athikesavan
- Unit of Environmental Health and Biotechnology, PG and Research Department of Zoology, Loyola Institute of Frontier Energy, Loyola College, Chennai-600 034, India
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27
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Röder C, Eggli S, EL-Kerdi A, Müller U, Ambrose T, Röösli E, Busato A, Aebi M. The International Documentation and Evaluation System (IDES)--10-years experience. Int Orthop 2003; 27:259-61. [PMID: 12904906 PMCID: PMC3461856 DOI: 10.1007/s00264-003-0498-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/04/2003] [Indexed: 11/26/2022]
Affiliation(s)
- C Röder
- Maurice E. Müller Center for Research in Orthopaedic Surgery, Institute for Evaluative Research in Orthopaedic Surgery, University of Bern, Switzerland.
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Vincent S, Ambrose T, Selvanayagam M. Impact of cadmium on food utilization of the Indian major carp, Catla catla (Ham). J Environ Biol 2002; 23:209-212. [PMID: 12602860] [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] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Catla catla, under the sublethal stress of cadmium exhibited depletion in food utilization parameters and it was concentration dependent. Heavy metal intoxication was found to exhibit reduction in biomass.
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Affiliation(s)
- S Vincent
- P. G. & Research Department of Zoology, Loyola College, Chennai-600 034, Tamilnadu, India.
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Abstract
STUDY DESIGN Ten cervical spine trauma subjects were studied during halovest treatment. Each subject wore each of three different vests. OBJECTIVES To compare the effect of vest design on loads between halo and vest during various activities. SUMMARY OF BACKGROUND DATA Complications during halovest use may be related to vest design, a variety of which are available. Loads between halo and vest have been shown to vary with activity type, but no comparison between vest types has been reported previously. METHODS Loads between the halo and the vest were measured during performance of activities of daily living and during load application to the halo, using custom-built four-channel transducers and a PC-based data acquisition system. RESULTS Substantial variations between subjects exist in loads between the halo and the vest. At rest, neck distraction loads were significantly greater for the supine posture than for either the sitting or standing postures. Loads applied to the halo by the investigators are carried by the neck and not by the structure connecting the halo to the vest. During activities of daily living all four measured load components are generally nonzero. During activities of daily living substantial differences in loads occurred between vest types. For all activities of daily living combined, the relative neck distraction load values were as follows: 4PAD 100%, Bremer 159%, and PMT 180%. CONCLUSIONS Previous evidence supports a connection between certain complications of halovest wear (such as pin loosening) and loads on the pins. This study shows that different halovests are associated with quite different loads between the vest and the halo (and thus loads on the pins and the neck). This is encouraging for prospective, clinical comparison of different halovests and for improvements in clinical performance through halovest design improvements.
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Affiliation(s)
- Yasuyuki Fukui
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
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Byers JM, Osofsky MS, Nadgorny B, Ambrose T, Cheng SF, Nowak J, Moodera JS, Barry A, Coey JMD. Measuring the spin polarization of a metal with a superconducting point contact. Science 1998; 282:85-8. [PMID: 9756482 DOI: 10.1126/science.282.5386.85] [Citation(s) in RCA: 1474] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
A superconducting point contact is used to determine the spin polarization at the Fermi energy of several metals. Because the process of supercurrent conversion at a superconductor-metal interface (Andreev reflection) is limited by the minority spin population near the Fermi surface, the differential conductance of the point contact can reveal the spin polarization of the metal. This technique has been applied to a variety of metals where the spin polarization ranges from 35 to 90 percent: Ni0.8Fe0.2, Ni, Co, Fe, NiMnSb, La0.7Sr0.3MnO3, and CrO2.
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Ambrose T, Chien CL. Finite-size effects and uncompensated magnetization in thin antiferromagnetic CoO layers. Phys Rev Lett 1996; 76:1743-1746. [PMID: 10060506 DOI: 10.1103/physrevlett.76.1743] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Ambrose T, Mani T, Vincent S, Kumar LC, Mathews KT. Biocontrol efficacy of Gerris (A) spinolae, Laccotrephes griseus and Gambusia affinis on larval mosquitoes. Indian J Malariol 1993; 30:187-92. [PMID: 8034107] [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] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Predation experiments using Gerris (A) spinolae, Laccotrephes griseus and Gambusia affinis were conducted against IV stage culicine larvae with varying prey densities. Ranking of individual predatory efficiency showed the sequence: large Gambusia > medium Gambusia > small Gambusia > female Laccotrephes > male Laccotrephes > Gerris. Predation under coexistence reveals the significance of predatory efficiency of different predator combinations with reference to prey density and exposure period.
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Affiliation(s)
- T Ambrose
- Research Department of Zoology, Loyola College, Madras, India
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Kopolovic R, Thrailkill KM, Martin DT, Ambrose T, Vento M, Carey LC, Cloutier CT. Effects of ibuprofen on a porcine model of acute respiratory failure. J Surg Res 1984; 36:300-5. [PMID: 6708494 DOI: 10.1016/0022-4804(84)90103-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Blockade of the arachidonic acid cascade has been shown to improve survival and hemodynamic alterations in animal models of sepsis and acute respiratory failure (ARF). The effects of intravenous ibuprofen, a cyclooxygenase inhibitor, were observed in 20-30 kg pigs with ARF induced by a continuous LD100 infusion of live Pseudomonas aeruginosa (2 X 10(8)/20 kg/min). Cardiopulmonary parameters were monitored in animals intubated, paralyzed, and ventilated at a 250-ml tidal volume and 0.5 FiO2. Pigs were randomly assigned to three groups: Group I received 2 bolus infusions of ibuprofen (12.5 mg/kg) at 20 and 210 min after baseline; Group II had Ps. aeruginosa (2 X 10(8) CFU/20 kg/min) only; Group III received Ps. aeruginosa and 12.5 mg/kg of ibuprofen at 20 and 210 min of ARF. Ibuprofen alone caused no significant changes in cardiorespiratory parameters. With Ps. aeruginosa infusion, significant pulmonary hypertension, hypoxemia, increased intrapulmonary shunt fraction, and systemic hypotension occurred. In the septic animals treated with ibuprofen, oxygenation was improved by a significant decrease in shunt, pulmonary edema, and pulmonary hypertension.
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