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Hughes N, Jia Y, Sujan M, Lawton T, Habli I, McDermid J. Contextual design requirements for decision-support tools involved in weaning patients from mechanical ventilation in intensive care units. Appl Ergon 2024; 118:104275. [PMID: 38574594 DOI: 10.1016/j.apergo.2024.104275] [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] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/06/2024]
Abstract
Weaning patients from ventilation in intensive care units (ICU) is a complex task. There is a growing desire to build decision-support tools to help clinicians during this process, especially those employing Artificial Intelligence (AI). However, tools built for this purpose should fit within and ideally improve the current work environment, to ensure they can successfully integrate into clinical practice. To do so, it is important to identify areas where decision-support tools may aid clinicians, and associated design requirements for such tools. This study analysed the work context surrounding the weaning process from mechanical ventilation in ICU environments, via cognitive task and work domain analyses. In doing so, both what cognitive processes clinicians perform during weaning, and the constraints and affordances of the work environment itself, were described. This study found a number of weaning process tasks where decision-support tools may prove beneficial, and from these a set of contextual design requirements were created. This work benefits researchers interested in creating human-centred decision-support tools for mechanical ventilation that are sensitive to the wider work system.
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Affiliation(s)
- Nathan Hughes
- University of York, Deramore Lane, York, YO10 5GH, UK.
| | - Yan Jia
- University of York, Deramore Lane, York, YO10 5GH, UK
| | | | - Tom Lawton
- University of York, Deramore Lane, York, YO10 5GH, UK; Improvement Academy, Bradford Institute for Health Research, Duckworth Lane, Bradford, BD9 6RJ, UK
| | - Ibrahim Habli
- University of York, Deramore Lane, York, YO10 5GH, UK
| | - John McDermid
- University of York, Deramore Lane, York, YO10 5GH, UK
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Lawton T, Morgan P, Porter Z, Hickey S, Cunningham A, Hughes N, Iacovides I, Jia Y, Sharma V, Habli I. Clinicians risk becoming 'liability sinks' for artificial intelligence. Future Healthc J 2024; 11:100007. [PMID: 38646041 PMCID: PMC11025047 DOI: 10.1016/j.fhj.2024.100007] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Affiliation(s)
- Tom Lawton
- Improvement Academy, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK
- Assuring Autonomy International Programme, University of York, Heslington, York YO10 5DD, UK
| | - Phillip Morgan
- York Law School, University of York, Heslington, York YO10 5DD, UK
| | - Zoe Porter
- Assuring Autonomy International Programme, University of York, Heslington, York YO10 5DD, UK
| | - Shireen Hickey
- Improvement Academy, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK
| | - Alice Cunningham
- Improvement Academy, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK
| | - Nathan Hughes
- Assuring Autonomy International Programme, University of York, Heslington, York YO10 5DD, UK
| | - Ioanna Iacovides
- Department of Computer Science, University of York, Heslington, York YO10 5DD, UK
| | - Yan Jia
- Assuring Autonomy International Programme, University of York, Heslington, York YO10 5DD, UK
| | - Vishal Sharma
- Improvement Academy, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK
| | - Ibrahim Habli
- Assuring Autonomy International Programme, University of York, Heslington, York YO10 5DD, UK
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Mebrahtu TF, McInerney CD, Benn J, McCrorie C, Granger J, Lawton T, Sheikh N, Habli I, Randell R, Johnson O. The impact of hospital command centre on patient flow and data quality: findings from the UK National Health Service. Int J Qual Health Care 2023; 35:mzad072. [PMID: 37750687 PMCID: PMC10566538 DOI: 10.1093/intqhc/mzad072] [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: 08/24/2022] [Revised: 05/25/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023] Open
Abstract
In the last 6 years, hospitals in developed countries have been trialling the use of command centres for improving organizational efficiency and patient care. However, the impact of these command centres has not been systematically studied in the past. It is a retrospective population-based study. Participants were patients who visited the Bradford Royal Infirmary hospital, Accident and Emergency (A&E) Department, between 1 January 2018 and 31 August 2021. Outcomes were patient flow (measured as A&E waiting time, length of stay, and clinician seen time) and data quality (measured by the proportion of missing treatment and assessment dates and valid transition between A&E care stages). Interrupted time-series segmented regression and process mining were used for analysis. A&E transition time from patient arrival to assessment by a clinician marginally improved during the intervention period; there was a decrease of 0.9 min [95% confidence interval (CI): 0.35-1.4], 3 min (95% CI: 2.4-3.5), 9.7 min (95% CI: 8.4-11.0), and 3.1 min (95% CI: 2.7-3.5) during 'patient flow program', 'command centre display roll-in', 'command centre activation', and 'hospital wide training program', respectively. However, the transition time from patient treatment until the conclusion of consultation showed an increase of 11.5 min (95% CI: 9.2-13.9), 12.3 min (95% CI: 8.7-15.9), 53.4 min (95% CI: 48.1-58.7), and 50.2 min (95% CI: 47.5-52.9) for the respective four post-intervention periods. Furthermore, the length of stay was not significantly impacted; the change was -8.8 h (95% CI: -17.6 to 0.08), -8.9 h (95% CI: -18.6 to 0.65), -1.67 h (95% CI: -10.3 to 6.9), and -0.54 h (95% CI: -13.9 to 12.8) during the four respective post-intervention periods. It was a similar pattern for the waiting and clinician seen times. Data quality as measured by the proportion of missing dates of records was generally poor (treatment date = 42.7% and clinician seen date = 23.4%) and did not significantly improve during the intervention periods. The findings of the study suggest that a command centre package that includes process change and software technology does not appear to have a consistent positive impact on patient safety and data quality based on the indicators and data we used. Therefore, hospitals considering introducing a command centre should not assume there will be benefits in patient flow and data quality.
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Affiliation(s)
- Teumzghi F Mebrahtu
- School of Computing, University of Leeds, Leeds LS2 9JT, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Duckworth Ln, Bradford BD9 6RJ, UK
| | - Ciaran D McInerney
- School of Computing, University of Leeds, Leeds LS2 9JT, UK
- Yorkshire and Humber Patient Safety Translational Research Centre, Wolfson Centre for Applied Health Research, Bradford Royal Infirmary, Duckworth Ln, Bradford BD9 6RJ, UK
| | - Jonathan Benn
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Duckworth Ln, Bradford BD9 6RJ, UK
- School of Psychology, University of Leeds, Woodhouse Lane, Leeds LS2 9JT, UK
| | - Carolyn McCrorie
- Yorkshire and Humber Patient Safety Translational Research Centre, Wolfson Centre for Applied Health Research, Bradford Royal Infirmary, Duckworth Ln, Bradford BD9 6RJ, UK
- School of Psychology, University of Leeds, Woodhouse Lane, Leeds LS2 9JT, UK
| | - Josh Granger
- School of Psychology, University of Leeds, Woodhouse Lane, Leeds LS2 9JT, UK
| | - Tom Lawton
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Duckworth Ln, Bradford BD9 6RJ, UK
| | - Naeem Sheikh
- Yorkshire and Humber Patient Safety Translational Research Centre, Wolfson Centre for Applied Health Research, Bradford Royal Infirmary, Duckworth Ln, Bradford BD9 6RJ, UK
| | - Ibrahim Habli
- Department of Computer Science, University of York, Heslington, York YO10 5DD, UK
| | - Rebecca Randell
- Wolfson Centre for Applied Health Research, Bradford Royal Infirmary, Duckworth Ln, Bradford BD9 6RJ, UK
- Faculty of Health Studies, University of Bradford, Richmond Rd, Bradford BD7 1DP, UK
| | - Owen Johnson
- School of Computing, University of Leeds, Leeds LS2 9JT, UK
- Yorkshire and Humber Patient Safety Translational Research Centre, Wolfson Centre for Applied Health Research, Bradford Royal Infirmary, Duckworth Ln, Bradford BD9 6RJ, UK
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Littlejohns A, Please H, Musasizi R, Murdoch S, Nampiina G, Waters I, Birch WD, de Boer G, Kapur N, Ambrozi T, Carol N, Noel N, Parmar J, Culmer P, Lawton T, Namulema E. Descriptive account of the first use of the LeVe CPAP System, a new frugal CPAP System, in adult patients with COVID-19 Pneumonitis in Uganda. Trop Med Health 2023; 51:42. [PMID: 37545001 PMCID: PMC10405477 DOI: 10.1186/s41182-023-00533-9] [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: 04/01/2023] [Accepted: 07/27/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) has been a key treatment modality for Coronavirus Disease 2019 (COVID-19) worldwide. Globally, the demand for CPAP outstripped the supply during the pandemic. The LeVe CPAP System was developed to provide respiratory support for treatment of COVID-19 and tailored for use in low- and middle-income country (LMIC) settings. Prior to formal trial approval, received in November 2021, these devices were used in extremis to support critically unwell adult patients requiring non-invasive ventilatory support. METHODS This is a retrospective descriptive review of adult patients with COVID-19 pneumonitis, who were treated with advanced respiratory support (CPAP and/or high-flow nasal oxygen, HFNO) at Mengo Hospital, Uganda. Patients were treated with the LeVe CPAP System, Elisa CPAP and/or AIRVO™ HFNO. Treatment was escalated per standard local protocols for respiratory failure, and CPAP was the maximum respiratory support available. Data were collected on patient characteristics, length of time of treatment, clinical outcome, and any adverse events. RESULTS Overall 333 patients were identified as COVID-19 positive, 44 received CPAP ± HFNO of which 43 were included in the study. The median age was 58 years (range 28-91 years) and 58% were female. The median duration of advanced respiratory support was 7 days (range 1-18 days). Overall (all device) mortality was 49% and this was similar between those started on the LeVe CPAP System and those started non-LeVe CPAP System devices (50% vs 47%). CONCLUSIONS The LeVe CPAP system was the most used CPAP device during the pandemic, bringing the hospital's number of available HFNO/CPAP devices from two to 14. They were a critical resource for providing respiratory support to the sickest group of patients when no alternative devices were available. The devices appear to be safe and well-tolerated with no serious adverse events recorded. This study is unable to assess the efficacy of the LeVe CPAP System; therefore, formal comparative studies are required to inform further use.
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Affiliation(s)
- Anna Littlejohns
- Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, West Yorkshire, UK
| | - Helen Please
- Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, West Yorkshire, UK
| | - Racheal Musasizi
- Mengo Hospital, Sir Albert Cook Road, Mengo, P. O. Box 7161, Kampala, Uganda
| | - Stuart Murdoch
- Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, West Yorkshire, UK
| | - Gorret Nampiina
- Mengo Hospital, Sir Albert Cook Road, Mengo, P. O. Box 7161, Kampala, Uganda
| | - Ian Waters
- University of Leeds, Woodhouse Lane, Leeds, LS2 9JT, UK
| | | | | | - Nikil Kapur
- University of Leeds, Woodhouse Lane, Leeds, LS2 9JT, UK
| | - Tumwesigye Ambrozi
- Mengo Hospital, Sir Albert Cook Road, Mengo, P. O. Box 7161, Kampala, Uganda
| | - Ninsiima Carol
- Mengo Hospital, Sir Albert Cook Road, Mengo, P. O. Box 7161, Kampala, Uganda
| | - Nakigudde Noel
- Mengo Hospital, Sir Albert Cook Road, Mengo, P. O. Box 7161, Kampala, Uganda
| | - Jiten Parmar
- Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, West Yorkshire, UK
| | - Peter Culmer
- University of Leeds, Woodhouse Lane, Leeds, LS2 9JT, UK
| | - Tom Lawton
- Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Ln, Bradford, BD9 6RJ, UK
| | - Edith Namulema
- Mengo Hospital, Sir Albert Cook Road, Mengo, P. O. Box 7161, Kampala, Uganda.
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Ozturk B, Lawton T, Smith S, Habli I. Predicting Progression of Type 2 Diabetes Using Primary Care Data with the Help of Machine Learning. Stud Health Technol Inform 2023; 302:38-42. [PMID: 37203605 DOI: 10.3233/shti230060] [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: 05/20/2023]
Abstract
Type 2 diabetes is a life-long health condition, and as it progresses, A range of comorbidities can develop. The prevalence of diabetes has increased gradually, and it is expected that 642 million adults will be living with diabetes by 2040. Early and proper interventions for managing diabetes-related comorbidities are important. In this study, we propose a Machine Learning (ML) model for predicting the risk of developing hypertension for patients who already have Type 2 diabetes. We used the Connected Bradford dataset, consisting of 1.4 million patients, as our main dataset for data analysis and model building. As a result of data analysis, we found that hypertension is the most frequent observation among patients having Type 2 diabetes. Since hypertension is very important to predict clinically poor outcomes such as risk of heart, brain, kidney, and other diseases, it is crucial to make early and accurate predictions of the risk of having hypertension for Type 2 diabetic patients. We used Naïve Bayes (NB), Neural Network (NN), Random Forest (RF), and Support Vector Machine (SVM) to train our model. Then we ensembled these models to see the potential performance improvement. The ensemble method gave the best classification performance values of accuracy and kappa values of 0.9525 and 0.2183, respectively. We concluded that predicting the risk of developing hypertension for Type 2 diabetic patients using ML provides a promising stepping stone for preventing the Type 2 diabetes progression.
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Affiliation(s)
| | - Tom Lawton
- University of York, York, YO10 5GH, UK
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford BD9 6RJ, UK
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Cook TM, Lawton T. Surgery soon after COVID-19: transparent big data have value but careful interpretation is still required. Anaesthesia 2023; 78:671-676. [PMID: 37094781 DOI: 10.1111/anae.16031] [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] [Accepted: 03/27/2023] [Indexed: 04/26/2023]
Affiliation(s)
- T M Cook
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- School of Medicine, University of Bristol, Bristol, UK
| | - T Lawton
- Improvement Academy, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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7
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Lawton T, Corp A, Horsfield C, McCooe M, Stonelake P, Whiteley S. Building on a novel bootstrapping modelling technique to predict region-wide critical care capacity requirements over the next decade. Future Healthc J 2023; 10:50-55. [PMID: 37786497 PMCID: PMC10538684 DOI: 10.7861/fhj.2022-0025] [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: 03/16/2023]
Abstract
We have previously described an open-source data-driven modelling technique that has been used to model critical care resource provision as well as expanded to elective surgery and even whole-hospital modelling. Here, we describe the use of this technique to model patient flow and resource use across the West Yorkshire Critical Care Network, with the advantage that recommendations can be made at an individual unit level for future resource provision, taking into account changes in population numbers and demography over the coming decade. We will be using this approach in other regions around the UK to help predict future critical care capacity requirements.
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Affiliation(s)
- Tom Lawton
- Bradford Institute for Health Research, Bradford, UK
| | - Aaron Corp
- Bradford Institute for Health Research, Bradford, UK
| | - Claire Horsfield
- West Yorkshire Critical Care and Major Trauma Operational Delivery Network, Leeds, UK
| | - Michael McCooe
- Improvement Academy, Bradford Institute for Health Research, Bradford, UK
| | - Paul Stonelake
- West Yorkshire Critical Care and Major Trauma Operational Delivery Network, Leeds, UK
| | - Simon Whiteley
- West Yorkshire Critical Care and Major Trauma Operational Delivery Network, Leeds, UK
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Mebrahtu TF, McInerney CD, Benn J, McCrorie C, Granger J, Lawton T, Sheikh N, Randell R, Habli I, Johnson OA. Effect of a hospital command centre on patient safety: an interrupted time series study. BMJ Health Care Inform 2023; 30:bmjhci-2022-100653. [PMID: 36697032 PMCID: PMC9884873 DOI: 10.1136/bmjhci-2022-100653] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 12/19/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Command centres have been piloted in some hospitals across the developed world in the last few years. Their impact on patient safety, however, has not been systematically studied. Hence, we aimed to investigate this. METHODS This is a retrospective population-based cohort study. Participants were patients who visited Bradford Royal Infirmary Hospital and Calderdale & Huddersfield hospitals between 1 January 2018 and 31 August 2021. A five-phase, interrupted time series, linear regression analysis was used. RESULTS After introduction of a Command Centre, while mortality and readmissions marginally improved, there was no statistically significant impact on postoperative sepsis. In the intervention hospital, when compared with the preintervention period, mortality decreased by 1.4% (95% CI 0.8% to 1.9%), 1.5% (95% CI 0.9% to 2.1%), 1.3% (95% CI 0.7% to 1.8%) and 2.5% (95% CI 1.7% to 3.4%) during successive phases of the command centre programme, including roll-in and activation of the technology and preparatory quality improvement work. However, in the control site, compared with the baseline, the weekly mortality also decreased by 2.0% (95% CI 0.9 to 3.1), 2.3% (95% CI 1.1 to 3.5), 1.3% (95% CI 0.2 to 2.4), 3.1% (95% CI 1.4 to 4.8) for the respective intervention phases. No impact on any of the indicators was observed when only the software technology part of the Command Centre was considered. CONCLUSION Implementation of a hospital Command Centre may have a marginal positive impact on patient safety when implemented as part of a broader hospital-wide improvement programme including colocation of operations and clinical leads in a central location. However, improvement in patient safety indicators was also observed for a comparable period in the control site. Further evaluative research into the impact of hospital command centres on a broader range of patient safety and other outcomes is warranted.
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Affiliation(s)
- Teumzghi F Mebrahtu
- School of Computing, University of Leeds, Leeds, UK,Bradford Institute for Health Research, Bradford, UK
| | - Ciarán D McInerney
- School of Computing, University of Leeds, Leeds, UK,Wolfson Centre for Applied Health Research, Bradford Royal Infirmary, Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
| | - Jonathan Benn
- Bradford Institute for Health Research, Bradford, UK,School of Psychology, University of Leeds, Leeds, West Yorkshire, UK
| | - Carolyn McCrorie
- Wolfson Centre for Applied Health Research, Bradford Royal Infirmary, Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK,School of Psychology, University of Leeds, Leeds, West Yorkshire, UK
| | - Josh Granger
- School of Psychology, University of Leeds, Leeds, West Yorkshire, UK
| | - Tom Lawton
- Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Naeem Sheikh
- Wolfson Centre for Applied Health Research, Bradford Royal Infirmary, Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
| | - Rebecca Randell
- Faculty of Health Studies, University of Bradford, Bradford, UK,Bradford Royal Infirmary, Wolfson Centre for Applied Health Research, Bradford, UK
| | - Ibrahim Habli
- Department of Computer Science, University of York, York, UK
| | - Owen Ashby Johnson
- School of Computing, University of Leeds, Leeds, UK,Wolfson Centre for Applied Health Research, Bradford Royal Infirmary, Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
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Sohal K, Mason D, Birkinshaw J, West J, McEachan RR, Elshehaly M, Cooper D, Shore R, McCooe M, Lawton T, Mon-Williams M, Sheldon T, Bates C, Wood M, Wright J. Connected Bradford: a Whole System Data Linkage Accelerator. Wellcome Open Res 2022; 7:26. [PMID: 36466951 PMCID: PMC9682213 DOI: 10.12688/wellcomeopenres.17526.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Accepted: 10/26/2022] [Indexed: 11/09/2022] Open
Abstract
The richness of linked population data provides exciting opportunities to understand local health needs, identify and predict those in most need of support and evaluate health interventions. There has been extensive investment to unlock the potential of clinical data for health research in the UK. However, most of the determinants of our health are social, economic, education, environmental, housing, food systems and are influenced by local authorities. The Connected Bradford Whole System Data Linkage Accelerator was set up to link health, education, social care, environmental and other local government data to drive learning health systems, prevention and population health management. Data spanning a period of over forty years has been linked for 800,000 individuals using the pseudonymised NHS number and other data variables. This prospective data collection captures near real time activity. This paper describes the dataset and our Connected Bradford Whole System Data Accelerator Framework that covers public engagement; practitioner and policy integration; legal and ethical approvals; information governance; technicalities of data linkage; data curation and guardianship; data validity and visualisation.
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Affiliation(s)
- Kuldeep Sohal
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - Dan Mason
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - John Birkinshaw
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - Jane West
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - Rosemary R.C. McEachan
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - Mai Elshehaly
- Department of Computer Science, University of Bradford, Bradford, BD7 1DP, UK
| | - Duncan Cooper
- Public Health, Bradford Metropolitan District Council, Bradford, BD1 1HX, UK
| | - Rob Shore
- Public Health, Bradford Metropolitan District Council, Bradford, BD1 1HX, UK
| | - Michael McCooe
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - Tom Lawton
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | | | - Trevor Sheldon
- Institute of Population Health Sciences, Queen Mary University of London, London, E1 4NS, UK
| | - Chris Bates
- The Phoenix Partnership, Leeds, LS18 5PX, UK
| | - Megan Wood
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - John Wright
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
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Lawton T, Wilkinson K, Corp A, Javid R, MacNally L, McCooe M, Newton E. Reduced critical care demand with early CPAP and proning in COVID-19 at Bradford: A single-centre cohort. J Intensive Care Soc 2022; 23:398-406. [PMID: 36751359 PMCID: PMC9679910 DOI: 10.1177/17511437211018615] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 01/16/2023] Open
Abstract
Background Guidance in COVID-19 respiratory failure has favoured early intubation, with concerns over the use of CPAP. We adopted early CPAP and self-proning, and evaluated the safety and efficacy of this approach. Methods This retrospective observational study included all patients with a positive COVID-19 PCR, and others with high clinical suspicion. Our protocol advised early CPAP and self-proning for severe cases, aiming to prevent rather than respond to deterioration. CPAP was provided outside critical care by ward staff supported by physiotherapists and an intensive critical care outreach program. Data were analysed descriptively and compared against a large UK cohort (ISARIC). Results 559 patients admitted before 1 May 2020 were included. 376 were discharged alive, and 183 died. 165 patients (29.5%) received CPAP, 40 (7.2%) were admitted to critical care and 28 (5.0%) were ventilated. Hospital mortality was 32.7%, and 50% for critical care. Following CPAP, 62% of patients with S:F or P:F ratios indicating moderate or severe ARDS, who were candidates for escalation, avoided intubation. Figures for critical care admission, intubation and hospital mortality are lower than ISARIC, whilst critical care mortality is similar. Following ISARIC proportions we would have admitted 92 patients to critical care and intubated 55. Using the described protocol, we intubated 28 patients from 40 admissions, and remained within our expanded critical care capacity. Conclusion Bradford's protocol produced good results despite our population having high levels of co-morbidity and ethnicities associated with poor outcomes. In particular we avoided overloading critical care capacity. We advocate this approach as both effective and safe.
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Affiliation(s)
- Tom Lawton
- Tom Lawton, Department of Anaesthesia &
Critical Care, Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal
Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK.
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Lawton T, Alwan NA. The UK COVID-19 Inquiry must examine the foundations of pandemic decision making. Lancet 2022; 400:1087-1089. [PMID: 35863367 PMCID: PMC9292634 DOI: 10.1016/s0140-6736(22)01332-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Tom Lawton
- Improvement Academy, Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Nisreen A Alwan
- School of Primary Care, Population Science and Medical Education, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK.
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13
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Best K, Alderson S, Alldred D, Bonnet L, Buchan I, Butters O, Farrin A, Foy R, Johnson O, McInerney C, Mehdizadeh D, Lawton T, Lawton R, Rodgers S, Teale E, Walker L, West R, Young B, Pirmohamed M, Clegg A. 825 DEVELOPMENT OF THE ANTICHOLINERGIC MEDICATION INDEX (ACMI). Age Ageing 2022. [DOI: 10.1093/ageing/afac035.825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Medications with Anticholinergic (AC) properties, are prescribed to treat a range of conditions. Older people are increasingly likely to be prescribed multiple AC medications, but are also more likely to experience unwanted adverse effects, such as falls and delirium. The risks of adverse outcomes increase with the number and potency of AC medications prescribed. The aim of this study was to use a prognostic modelling approach to develop an AC Medication Index (ACMI) that identifies patients at high risk of AC medication side effects.
Methods
The prognostic model was developed using data on patients aged 65–95 years, registered with a general practice contributing data to ‘Connected Bradford’ in 2019. A Time-dependent Cox model was fitted, with hospital admission for delirium or falls as the composite outcome and AC medications, age, sex and important clinical factors (e.g. dementia, arthritis, urinary incontinence) as predictors. Concordance and Negalkerke’s R2 derived from five-fold cross-validation were used to assess model performance.
Results
There were 151,604 patients included in the study, of whom 47,035 (31.0%) were prescribed ≥1 AC medication during 2019. Codeine, Prednisolone, Furosemide and Amitriptyline were most commonly prescribed with 7.4%, 4.0%, 3.8% and 3.1% of patients prescribed these medications at least once in 2019, respectively. During 2019, 6,078 (4.0%) patients experienced a hospital admission with delirium or a fall, with the rate being increased in those prescribed ≥1 AC medication during 2019 (4.8% vs 3.7%; p < 0.001). The prognostic model yielded a discrimination statistic of 0.86 with an R2 of 0.1.
Conclusion
The model used to develop the ACMI shows good discrimination. External validation will soon be performed using data from the SAIL databank and the ACMI will be further developed as a tool for use in primary care.
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Affiliation(s)
| | - S Alderson
- University of Leeds
- NHS Greater Huddersfield CCG
| | | | | | | | | | | | | | | | | | | | - T Lawton
- Bradford Teaching Hospitals NHS Foundation Trust
| | | | | | - E Teale
- University of Leeds
- Bradford Teaching Hospitals NHS Foundation Trust
| | | | | | | | | | - A Clegg
- University of Leeds
- Bradford Teaching Hospitals NHS Foundation Trust
- NHS Leeds CCG
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14
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McInerney C, McCrorie C, Benn J, Habli I, Lawton T, Mebrahtu TF, Randell R, Sheikh N, Johnson O. Evaluating the safety and patient impacts of an artificial intelligence command centre in acute hospital care: a mixed-methods protocol. BMJ Open 2022; 12:e054090. [PMID: 35232784 PMCID: PMC8889317 DOI: 10.1136/bmjopen-2021-054090] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION This paper presents a mixed-methods study protocol that will be used to evaluate a recent implementation of a real-time, centralised hospital command centre in the UK. The command centre represents a complex intervention within a complex adaptive system. It could support better operational decision-making and facilitate identification and mitigation of threats to patient safety. There is, however, limited research on the impact of such complex health information technology on patient safety, reliability and operational efficiency of healthcare delivery and this study aims to help address that gap. METHODS AND ANALYSIS We will conduct a longitudinal mixed-method evaluation that will be informed by public-and-patient involvement and engagement. Interviews and ethnographic observations will inform iterations with quantitative analysis that will sensitise further qualitative work. Quantitative work will take an iterative approach to identify relevant outcome measures from both the literature and pragmatically from datasets of routinely collected electronic health records. ETHICS AND DISSEMINATION This protocol has been approved by the University of Leeds Engineering and Physical Sciences Research Ethics Committee (#MEEC 20-016) and the National Health Service Health Research Authority (IRAS No.: 285933). Our results will be communicated through peer-reviewed publications in international journals and conferences. We will provide ongoing feedback as part of our engagement work with local trust stakeholders.
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Affiliation(s)
- Ciarán McInerney
- School of Computing, University of Leeds Faculty of Engineering and Physical Sciences, Leeds, UK
- Bradford Royal Infirmary, Wolfson Centre for Applied Health Research, Bradford, UK
| | - Carolyn McCrorie
- Bradford Royal Infirmary, Wolfson Centre for Applied Health Research, Bradford, UK
- School of Psychology, University of Leeds Faculty of Social Sciences, Leeds, UK
| | - Jonathan Benn
- Bradford Royal Infirmary, Wolfson Centre for Applied Health Research, Bradford, UK
- School of Psychology, University of Leeds Faculty of Social Sciences, Leeds, UK
| | - Ibrahim Habli
- Department of Computer Science, University of York, York, UK
| | - Tom Lawton
- Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Teumzghi F Mebrahtu
- School of Computing, University of Leeds Faculty of Engineering and Physical Sciences, Leeds, UK
| | - Rebecca Randell
- Bradford Royal Infirmary, Wolfson Centre for Applied Health Research, Bradford, UK
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Naeem Sheikh
- Bradford Royal Infirmary, Wolfson Centre for Applied Health Research, Bradford, UK
| | - Owen Johnson
- School of Computing, University of Leeds Faculty of Engineering and Physical Sciences, Leeds, UK
- Bradford Royal Infirmary, Wolfson Centre for Applied Health Research, Bradford, UK
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Sohal K, Mason D, Birkinshaw J, West J, McEachan RR, Elshehaly M, Cooper D, Shore R, McCooe M, Lawton T, Mon-Williams M, Sheldon T, Bates C, Wood M, Wright J. Connected Bradford: a Whole System Data Linkage Accelerator. Wellcome Open Res 2022; 7:26. [PMID: 36466951 PMCID: PMC9682213 DOI: 10.12688/wellcomeopenres.17526.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Accepted: 12/22/2021] [Indexed: 11/20/2022] Open
Abstract
The richness of linked population data provides exciting opportunities to understand local health needs, identify and predict those in most need of support and evaluate health interventions. There has been extensive investment to unlock the potential of clinical data for health research in the UK. However, most of the determinants of our health are social, economic, education, environmental, housing, food systems and are influenced by local authorities. The Connected Bradford Whole System Data Linkage Accelerator was set up to link health, education, social care, environmental and other local government data to drive learning health systems, prevention and population health management. Data spanning a period of over forty years has been linked for 800,000 individuals using the pseudonymised NHS number and other data variables. This prospective data collection captures near real time activity. This paper describes the dataset and our Connected Bradford Whole System Data Accelerator Framework that covers public engagement; practitioner and policy integration; legal and ethical approvals; information governance; technicalities of data linkage; data curation and guardianship; data validity and visualisation.
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Affiliation(s)
- Kuldeep Sohal
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - Dan Mason
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - John Birkinshaw
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - Jane West
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - Rosemary R.C. McEachan
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - Mai Elshehaly
- Department of Computer Science, University of Bradford, Bradford, BD7 1DP, UK
| | - Duncan Cooper
- Public Health, Bradford Metropolitan District Council, Bradford, BD1 1HX, UK
| | - Rob Shore
- Public Health, Bradford Metropolitan District Council, Bradford, BD1 1HX, UK
| | - Michael McCooe
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - Tom Lawton
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | | | - Trevor Sheldon
- Institute of Population Health Sciences, Queen Mary University of London, London, E1 4NS, UK
| | - Chris Bates
- The Phoenix Partnership, Leeds, LS18 5PX, UK
| | - Megan Wood
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
| | - John Wright
- Bradford Institute for Health Research, Bradford Hospitals National Health Service Trust, Bradford, BD9 6RJ, UK
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Lawton T, Butler M, Peters C. Airborne protection for staff is associated with reduced hospital-acquired COVID-19 in English NHS Trusts. J Hosp Infect 2021; 120:81-84. [PMID: 34861313 PMCID: PMC8631043 DOI: 10.1016/j.jhin.2021.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 12/01/2022]
Abstract
Introduction The rate of hospital-acquired coronavirus disease 2019 has reduced from 14.3% to 4.2% over the last year, but substantial differences still exist between English National Health Service (NHS) hospital trusts. Methods This study assessed rates of hospital-acquired infection (HAI), comparing NHS hospital trusts using airborne respiratory protection (e.g. FFP3 masks) for all staff, as a marker of measures to reduce airborne spread, with NHS hospital trusts using mainly droplet precautions (e.g. surgical masks). Results/discussion The use of respiratory protective equipment was associated with a 33% reduction in the odds of HAI in the Delta wave, and a 21% reduction in the odds of HAI in the Alpha wave (P<0.00001). It is recommended that all hospitals should prioritize airborne mitigation.
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Affiliation(s)
- T Lawton
- Improvement Academy Data Analytics Unit, Bradford, UK.
| | - M Butler
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - C Peters
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
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17
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Haas LEM, Boumendil A, Flaatten H, Guidet B, Ibarz M, Jung C, Moreno R, Morandi A, Andersen FH, Zafeiridis T, Walther S, Oeyen S, Leaver S, Watson X, Boulanger C, Szczeklik W, Schefold JC, Cecconi M, Marsh B, Joannidis M, Nalapko Y, Elhadi M, Fjølner J, Artigas A, de Lange DW, Joannidis M, Eller P, Helbok R, Schmutz R, Nollet J, de Neve N, De Buysscher P, Oeyen S, Swinnen W, Mikačić M, Bastiansen A, Husted A, Dahle BES, Cramer C, Sølling C, Ørsnes D, Thomsen JE, Pedersen JJ, Enevoldsen MH, Elkmann T, Kubisz-Pudelko A, Pope A, Collins A, Raj AS, Boulanger C, Frey C, Hart C, Bolger C, Spray D, Randell G, Filipe H, Welters ID, Grecu I, Evans J, Cupitt J, Lord J, Henning J, Jones J, Ball J, North J, Salaunkey K, De Gordoa LOR, Bell L, Balasubramaniam M, Vizcaychipi M, Faulkner M, Mupudzi M, Lea-Hagerty M, Reay M, Spivey M, Love N, Spittle NSN, White N, Williams P, Morgan P, Wakefield P, Savine R, Jacob R, Innes R, Kapoor R, Humphreys S, Rose S, Dowling S, Leaver S, Mane T, Lawton T, Ogbeide V, Khaliq W, Baird Y, Romen A, Galbois A, Guidet B, Vinsonneau C, Charron C, Thevenin D, Guerot E, Besch G, Savary G, Mentec H, Chagnon JL, Rigaud JP, Quenot JP, Castaneray J, Rosman J, Maizel J, Tiercelet K, Vettoretti L, Hovaere MM, Messika M, Djibré M, Rolin N, Burtin P, Garcon P, Nseir S, Valette X, Rabe C, Barth E, Ebelt H, Fuest K, Franz M, Horacek M, Schuster M, Meybohm P, Bruno RR, Allgäuer S, Dubler S, Schaller SJ, Schering S, Steiner S, Dieck T, Rahmel T, Graf T, Koutsikou A, Vakalos A, Raitsiou B, Flioni EN, Neou E, Tsimpoukas F, Papathanakos G, Marinakis G, Koutsodimitropoulos I, Aikaterini K, Rovina N, Kourelea S, Polychronis T, Zidianakis V, Konstantinia V, Aidoni Z, Marsh B, Motherway C, Read C, Martin-Loeches I, Cracchiolo AN, Morigi A, Calamai I, Brusa S, Elhadi A, Tarek A, Khaled A, Ahmed H, Belkhair WA, Cornet AD, Gommers D, de Lange D, van Boven E, Haringman J, Haas L, van den Berg L, Hoiting O, de Jager P, Gerritsen RT, Dormans T, Dieperink W, Breidablik ABA, Slapgard A, Rime AK, Jannestad B, Sjøbøe B, Rice E, Andersen FH, Strietzel HF, Jensen JP, Langørgen J, Tøien K, Strand K, Hahn M, Klepstad P, Biernacka A, Kluzik A, Kudlinski B, Maciejewski D, Studzińska D, Hymczak H, Stefaniak J, Solek-Pastuszka J, Zorska J, Cwyl K, Krzych LJ, Zukowski M, Lipińska-Gediga M, Pietruszko M, Piechota M, Serwa M, Czuczwar M, Ziętkiewicz M, Kozera N, Nasiłowski P, Sendur P, Zatorski P, Galkin P, Gawda R, Kościuczuk U, Cyrankiewicz W, Gola W, Pinto AF, Fernandes AM, Santos AR, Sousa C, Barros I, Ferreira IA, Blanco JB, Carvalho JT, Maia J, Candeias N, Catorze N, Belskiy V, Lores A, Mira AP, Cilloniz C, Perez-Torres D, Maseda E, Rodriguez E, Prol-Silva E, Eixarch G, Gomà G, Aguilar G, Velasco GN, Jaimes MI, Villamayor MI, Fernández NL, Cubero PJ, López-Cuenca S, Tomasa T, Sjöqvist A, Brorsson C, Schiöler F, Westberg H, Nauska J, Sivik J, Berkius J, Thiringer KK, De Geer L, Walther S, Boroli F, Schefold JC, Hergafi L, Eckert P, Yıldız I, Yovenko I, Nalapko Y, Nalapko Y, Pugh R. Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old: results from an observational study in 241 European ICUs. Age Ageing 2021; 50:1719-1727. [PMID: 33744918 DOI: 10.1093/ageing/afab036] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 10/20/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear. OBJECTIVE To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function. DESIGN Prospective cohort study. SETTING 241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019. SUBJECTS Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2. METHODS Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected. RESULTS Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P < 0.0001), SOFA (per one-point): HR, 1.16 (95% CI, 1.14-1.17, P < 0.0001) and frailty (CFS > 4): HR, 1.34 (95% CI, 1.18-1.51, P < 0.0001). CONCLUSIONS There is substantial long-term mortality in VIPs admitted with sepsis. Frailty, age and disease severity were identified as predictors of long-term mortality in VIPs admitted with sepsis.
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Affiliation(s)
- Lenneke E M Haas
- Department of Intensive Care Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Ariane Boumendil
- Assistance Publique-Hôpital de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale. Paris F-75012, France
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- Institut Pierre Louis d’Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Service de Réanimation, Sorbonne Université, INSERM, F75012 Paris, France
| | - Mercedes Ibarz
- Department of Intensive Care Medicine, Universitary Hospital Sagrat Cor Barcelona, Spain
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Rui Moreno
- Unidade de Cuidados Intensivos Neurocríticos e Trauma. Hospital de São José, Centro Hospitalar, Faculdade de Ciências Médicas de Lisboa (Nova Medical School), Universitário de Lisboa Central, Lisbon, Portugal
| | - Alessandro Morandi
- Department of Rehabilitation and Aged Care, Hospital Ancelle, Cremona, Italy. Parc Sanitari Pere Virgili and Vall d’Hebrón Institute of Research, Barcelona, Spain
| | - Finn H Andersen
- Department of Anaesthesia and Intensive Care, Ålesund Hospital, Ålesund, Norway, Department of Circulation and Medical Imaging, NTNU, Trondheim, Norway
| | | | - Sten Walther
- Department of Cardiothoracic and Vascular Surgery, Heart Centre, Linköping University Hospital, Linköping, Sweden
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent, Belgium
| | - Susannah Leaver
- Research Lead Critical Care Directorate St George's University Hospital, NHS Foundation Trust, London, UK
| | | | - Carole Boulanger
- Chair NAHP Section ESICM, Intensive Care Unit, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Wojciech Szczeklik
- Intensive Care and Perioperative Medicine Division, Jagiellonian University Medical College, Kraków, Poland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Universitätsspital, University of Bern, Bern, Switzerland
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni 56, 20089, Rozzano, MI, Italy. Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Rozzano, MI, Italy
| | - Brian Marsh
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Yuriy Nalapko
- European Wellness International, ICU, Luhansk, Ukraine
| | | | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona. Sabadell, Spain
| | - Dylan W de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
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Culmer P, Davis Birch W, Waters I, Keeling A, Osnes C, Jones D, de Boer G, Hetherington R, Ashton S, Latham M, Beacon T, Royston T, Miller R, Littlejohns A, Parmar J, Lawton T, Murdoch S, Brettle D, Musasizi R, Nampiina G, Namulema E, Kapur N. The LeVe CPAP System for Oxygen-Efficient CPAP Respiratory Support: Development and Pilot Evaluation. Front Med Technol 2021; 3:715969. [PMID: 35047948 PMCID: PMC8757765 DOI: 10.3389/fmedt.2021.715969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/29/2021] [Indexed: 12/04/2022] Open
Abstract
Background: The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has placed a significant demand on healthcare providers (HCPs) to provide respiratory support for patients with moderate to severe symptoms. Continuous Positive Airway Pressure (CPAP) non-invasive ventilation can help patients with moderate symptoms to avoid the need for invasive ventilation in intensive care. However, existing CPAP systems can be complex (and thus expensive) or require high levels of oxygen, limiting their use in resource-stretched environments. Technical Development + Testing: The LeVe ("Light") CPAP system was developed using principles of frugal innovation to produce a solution of low complexity and high resource efficiency. The LeVe system exploits the air flow dynamics of electric fan blowers which are inherently suited to delivery of positive pressure at appropriate flow rates for CPAP. Laboratory evaluation demonstrated that performance of the LeVe system was equivalent to other commercially available systems used to deliver CPAP, achieving a 10 cm H2O target pressure within 2.4% RMS error and 50-70% FiO2 dependent with 10 L/min oxygen from a commercial concentrator. Pilot Evaluation: The LeVe CPAP system was tested to evaluate safety and acceptability in a group of ten healthy volunteers at Mengo Hospital in Kampala, Uganda. The study demonstrated that the system can be used safely without inducing hypoxia or hypercapnia and that its use was well-tolerated by users, with no adverse events reported. Conclusions: To provide respiratory support for the high patient numbers associated with the COVID-19 pandemic, healthcare providers require resource efficient solutions. We have shown that this can be achieved through frugal engineering of a CPAP ventilation system, in a system which is safe for use and well-tolerated in healthy volunteers. This approach may also benefit other respiratory conditions which often go unaddressed in Low and Middle Income Countries (LMICs) for want of context-appropriate technology designed for the limited oxygen resources available.
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Affiliation(s)
- Pete Culmer
- School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
| | - W. Davis Birch
- School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
| | - I. Waters
- School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
| | - A. Keeling
- School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
- School of Dentistry, University of Leeds, Leeds, United Kingdom
| | - C. Osnes
- School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
- School of Dentistry, University of Leeds, Leeds, United Kingdom
| | - D. Jones
- School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
| | - G. de Boer
- School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
| | - R. Hetherington
- School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
| | - S. Ashton
- Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - M. Latham
- Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - T. Beacon
- Medical Aid International Ltd., Bedford, United Kingdom
| | - T. Royston
- Medical Aid International Ltd., Bedford, United Kingdom
| | - R. Miller
- Medical Aid International Ltd., Bedford, United Kingdom
| | | | - J. Parmar
- Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Tom Lawton
- Bradford Teaching Hospitals National Health Service (NHS) Foundation Trust, Bradford, United Kingdom
| | - S. Murdoch
- Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - D. Brettle
- Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | | | | | | | - N. Kapur
- School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom
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Cammarota G, Esposito T, Azzolina D, Cosentini R, Menzella F, Aliberti S, Coppadoro A, Bellani G, Foti G, Grasselli G, Cecconi M, Pesenti A, Vitacca M, Lawton T, Ranieri VM, Di Domenico SL, Resta O, Gidaro A, Potalivo A, Nardi G, Brusasco C, Tesoro S, Navalesi P, Vaschetto R, De Robertis E. Noninvasive respiratory support outside the intensive care unit for acute respiratory failure related to coronavirus-19 disease: a systematic review and meta-analysis. Crit Care 2021; 25:268. [PMID: 34330320 PMCID: PMC8324455 DOI: 10.1186/s13054-021-03697-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/21/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU. METHODS We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders. RESULTS Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30-41%]. 26% [21-30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36-54%]. 23% [15-32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65-78%]. Oxygenation on admission was the main source of between-study heterogeneity. CONCLUSIONS During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance. REGISTRATION PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.
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Affiliation(s)
- Gianmaria Cammarota
- Department of Medicine and Surgery, University of Perugia, Piazza Università 1, 06123, Perugia, Italy.
| | - Teresa Esposito
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Danila Azzolina
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | | | - Francesco Menzella
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS Di Reggio Emilia, Reggio Emilia, Italy
| | - Stefano Aliberti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Giacomo Bellani
- ASST Monza, San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giuseppe Foti
- ASST Monza, San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Vitacca
- Respiratory Rehabilitation Unit Lumezzane, ICS Maugeri IRCCS, Brescia, Italy
| | - Tom Lawton
- Department of Anesthesia and Critical Care, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - V Marco Ranieri
- Anesthesia and Intensive Care Medicine, Policlinico Di Sant'Orsola, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | | | - Onofrio Resta
- Cardiothoracic Department, Respiratory Unit, University Hospital, Bari, Italy
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Ospedale Luigi Sacco, Milan, Italy
| | - Antonella Potalivo
- Department of Anesthesia and Intensive Care, Infermi Hospital, AUSL Della Romagna, Rimini, Italy
| | - Giuseppe Nardi
- Department of Anesthesia and Intensive Care, Infermi Hospital, AUSL Della Romagna, Rimini, Italy
| | - Claudia Brusasco
- Anesthesia and Intensive Care Unit, E.O. Ospedali Galliera, Genoa, Italy
| | - Simonetta Tesoro
- Department of Medicine and Surgery, University of Perugia, Piazza Università 1, 06123, Perugia, Italy
| | - Paolo Navalesi
- Department of Medicine-DIMED, Università Di Padova, Padua, Italy
| | - Rosanna Vaschetto
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Edoardo De Robertis
- Department of Medicine and Surgery, University of Perugia, Piazza Università 1, 06123, Perugia, Italy
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Santorelli G, McCooe M, Sheldon TA, Wright J, Lawton T. Ethnicity, pre-existing comorbidities, and outcomes of hospitalised patients with COVID-19. Wellcome Open Res 2021; 6:32. [PMID: 34522788 PMCID: PMC8408538 DOI: 10.12688/wellcomeopenres.16580.2] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 12/24/2022] Open
Abstract
Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in thousands of deaths in the UK. Those with existing comorbidities and minority ethnic groups have been found to be at increased risk of mortality. We wished to determine if there were any differences in intensive care unit (ICU) admission and 30-day hospital mortality in a city with high levels of deprivation and a large community of people of South Asian heritage. Methods: Detailed information on 582 COVID-19-positive inpatients in Bradford and Calderdale between February-August 2020 were extracted from Electronic Health Records. Logistic regression and Cox proportional hazards models were used to explore the relationship between ethnicity with admission to ICU and 30-day mortality, respectively accounting for the effect of demographic and clinical confounders. Results: The sample consisted of 408 (70%) White, 142 (24%) South Asian and 32 (6%) other minority ethnic patients. Ethnic minority patients were younger, more likely to live in deprived areas, and be overweight/obese, have type 2 diabetes, hypertension and asthma compared to white patients, but were less likely to have cancer (South Asian patients only) and COPD. Male and obese patients were more likely to be admitted to ICU, and patients of South Asian ethnicity, older age, and those with cancer were less likely. Being male, older age, deprivation, obesity, and cancer were associated with 30-day mortality. The risk of death in South Asian patients was the same as in white patients HR 1.03 (0.58, 1.82). Conclusions: Despite South Asian patients being less likely to be admitted to ICU and having a higher prevalence of diabetes and obesity, there was no difference in the risk of death compared to white patients. This contrasts with other findings and highlights the value of studies of communities which may have different ethnic, deprivation and clinical risk profiles.
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Affiliation(s)
- Gillian Santorelli
- Bradford Institute for Health Research, Bradford, West Yorkshire, BD9 6RJ, UK
| | - Michael McCooe
- Bradford Institute for Health Research, Bradford, West Yorkshire, BD9 6RJ, UK
| | - Trevor A. Sheldon
- Bradford Institute for Health Research, Bradford, West Yorkshire, BD9 6RJ, UK
- Institute for Population Health Sciences, Barts and The London NHS Trust, Queen Mary University of London, London, E1 4NS, UK
| | - John Wright
- Bradford Institute for Health Research, Bradford, West Yorkshire, BD9 6RJ, UK
| | - Tom Lawton
- Bradford Institute for Health Research, Bradford, West Yorkshire, BD9 6RJ, UK
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21
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Santorelli G, McCooe M, Sheldon TA, Wright J, Lawton T. Ethnicity, pre-existing comorbidities, and outcomes of hospitalised patients with COVID-19. Wellcome Open Res 2021; 6:32. [PMID: 34522788 PMCID: PMC8408538 DOI: 10.12688/wellcomeopenres.16580.1] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 04/04/2024] Open
Abstract
Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in thousands of deaths in the UK. Those with existing comorbidities and minority ethnic groups have been found to be at increased risk of mortality. We wished to determine if there were any differences in intensive care unit (ICU) admission and 30-day hospital mortality in a city with high levels of deprivation and a large community of people of South Asian heritage. Methods: Detailed information on 622 COVID-19-positive inpatients in Bradford and Calderdale between February-August 2020 were extracted from Electronic Health Records. Logistic regression and Cox proportional hazards models were used to explore the relationship between ethnicity with admission to ICU and 30-day mortality, respectively accounting for the effect of demographic and clinical confounders. Results: The sample consisted of 408 (70%) White, 142 (24%) South Asian and 32 (6%) other minority ethnic patients. Ethnic minority patients were younger, more likely to live in deprived areas, and be overweight/obese, have type 2 diabetes, hypertension and asthma compared to white patients, but were less likely to have cancer (South Asian patients only) and COPD. Male and obese patients were more likely to be admitted to ICU, and patients of South Asian ethnicity, older age, and those with cancer were less likely. Being male, older age, deprivation, obesity, and cancer were associated with 30-day mortality. The risk of death in South Asian patients was the same as in white patients HR 1.03 (0.58, 1.82). Conclusions: Despite South Asian patients being less likely to be admitted to ICU and having a higher prevalence of diabetes and obesity, there was no difference in the risk of death compared to white patients. This contrasts with other findings and highlights the value of studies of communities which may have different ethnic, deprivation and clinical risk profiles.
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Affiliation(s)
- Gillian Santorelli
- Bradford Institute for Health Research, Bradford, West Yorkshire, BD9 6RJ, UK
| | - Michael McCooe
- Bradford Institute for Health Research, Bradford, West Yorkshire, BD9 6RJ, UK
| | - Trevor A. Sheldon
- Bradford Institute for Health Research, Bradford, West Yorkshire, BD9 6RJ, UK
- Institute for Population Health Sciences, Barts and The London NHS Trust, Queen Mary University of London, London, E1 4NS, UK
| | - John Wright
- Bradford Institute for Health Research, Bradford, West Yorkshire, BD9 6RJ, UK
| | - Tom Lawton
- Bradford Institute for Health Research, Bradford, West Yorkshire, BD9 6RJ, UK
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Habli I, Alexander R, Hawkins R, Sujan M, McDermid J, Picardi C, Lawton T. Enhancing COVID-19 decision making by creating an assurance case for epidemiological models. BMJ Health Care Inform 2020; 27:bmjhci-2020-100165. [PMID: 32900694 PMCID: PMC7477796 DOI: 10.1136/bmjhci-2020-100165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/10/2020] [Accepted: 07/16/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ibrahim Habli
- Department of Computer Science, University of York, York, North Yorkshire, UK
| | - Rob Alexander
- Department of Computer Science, University of York, York, North Yorkshire, UK
| | - Richard Hawkins
- Department of Computer Science, University of York, York, North Yorkshire, UK
| | - Mark Sujan
- Department of Social Science and Systems in Health, Warwick Medical School, University of Warwick, Coventry, UK
| | - John McDermid
- Department of Computer Science, University of York, York, North Yorkshire, UK
| | - Chiara Picardi
- Department of Computer Science, University of York, York, North Yorkshire, UK
| | - Tom Lawton
- Department of Anaesthesia and Critical Care, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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23
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Habli I, Lawton T, Porter Z. Artificial intelligence in health care: accountability and safety. Bull World Health Organ 2020; 98:251-256. [PMID: 32284648 PMCID: PMC7133468 DOI: 10.2471/blt.19.237487] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 01/13/2023] Open
Abstract
The prospect of patient harm caused by the decisions made by an artificial intelligence-based clinical tool is something to which current practices of accountability and safety worldwide have not yet adjusted. We focus on two aspects of clinical artificial intelligence used for decision-making: moral accountability for harm to patients; and safety assurance to protect patients against such harm. Artificial intelligence-based tools are challenging the standard clinical practices of assigning blame and assuring safety. Human clinicians and safety engineers have weaker control over the decisions reached by artificial intelligence systems and less knowledge and understanding of precisely how the artificial intelligence systems reach their decisions. We illustrate this analysis by applying it to an example of an artificial intelligence-based system developed for use in the treatment of sepsis. The paper ends with practical suggestions for ways forward to mitigate these concerns. We argue for a need to include artificial intelligence developers and systems safety engineers in our assessments of moral accountability for patient harm. Meanwhile, none of the actors in the model robustly fulfil the traditional conditions of moral accountability for the decisions of an artificial intelligence system. We should therefore update our conceptions of moral accountability in this context. We also need to move from a static to a dynamic model of assurance, accepting that considerations of safety are not fully resolvable during the design of the artificial intelligence system before the system has been deployed.
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Affiliation(s)
- Ibrahim Habli
- Department of Computer Science, University of York, Deramore Lane, Heslington, York YO10 5GH, England
| | - Tom Lawton
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, England
| | - Zoe Porter
- Department of Philosophy, University of York, York, England
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24
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Burton S, Habli I, Lawton T, McDermid J, Morgan P, Porter Z. Mind the gaps: Assuring the safety of autonomous systems from an engineering, ethical, and legal perspective. ARTIF INTELL 2020. [DOI: 10.1016/j.artint.2019.103201] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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25
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Jia Y, Lawton T, White S, Habli I. Developing a Safety Case for Electronic Prescribing. Stud Health Technol Inform 2019; 264:629-633. [PMID: 31438000 DOI: 10.3233/shti190299] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
It is now recognised that Health IT systems can bring benefits to healthcare, but they can also introduce new causes of risks that contribute to patient harm. This paper focuses on approaches to modelling and analysing potential causes of medication errors, particularly those arising from the use of Electronic Prescribing. It sets out a systematic way of analysing hazards, their causes and consequences, drawing on the expertise of a multidisciplinary team. The analysis results are used to support the development of a safety case for a large-scale Health IT system in use in three teaching hospitals. The paper shows how elements of the safety case can be updated dynamically. We show that it is valuable to use the dynamically updated elements to inform clinicians about changes in risk, and thus prompt changes in practice to mitigate the risks.
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Affiliation(s)
- Yan Jia
- Department of Computer Science, University of York, York UK
| | - Tom Lawton
- Bradford Royal Infirmary and Bradford Institute for Health Research, Bradford UK
| | | | - Ibrahim Habli
- Department of Computer Science, University of York, York UK
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26
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Habli I, Jia Y, White S, Gabriel G, Lawton T, Sujan M, Tomsett C. Development and piloting of a software tool to facilitate proactive hazard and risk analysis of Health Information Technology. Health Informatics J 2019; 26:683-702. [DOI: 10.1177/1460458219852789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Health Information Technology is now widely promoted as a means for improving patient safety. The technology could also, under certain conditions, pose hazards to patient safety. However, current definitions of hazards are generic and hard to interpret, particularly for large Health Information Technology in complex socio-technical settings, that is, involving interacting clinical, organisational and technological factors. In this article, we develop a new conceptualisation for the notion of hazards and implement this conceptualisation in a tool-supported methodology called the Safety Modelling, Assurance and Reporting Toolset (SMART). The toolset aims to support clinicians and engineers in performing hazard identification and risk analysis and producing a safety case for Health Information Technology. Through a pilot study, we used and examined the toolset for developing a safety case for electronic prescribing in three acute hospitals. Our results demonstrate the ability of the approach to ensure that the safety evidence is generated based on explicit traceability between the clinical models and Health Information Technology functionality. They also highlight challenges concerning identifying hazards in a consistent way, with clear impact on patient safety in order to facilitate clinically meaningful risk analysis.
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Affiliation(s)
| | | | | | | | - Tom Lawton
- Bradford Royal Infirmary, UK; Bradford Institute for Health Research, UK
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27
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Abstract
Modelling is an under-used tool in the NHS operationally; this is primarily due to a lack of familiarity, but also due to the complex nature of the healthcare system, lack of sufficiently detailed data, and difficulties trying to distil the heterogeneity of individual patient experience into manageable groups. This paper describes a model of patient flow and resource use on the critical care unit at Bradford Royal Infirmary, -produced using a novel technique which helps avoid these issues by using genuine routinely collected historical data in lieu of trying to model individual patients. This has had -unexpected benefits in terms of engagement with the model as it is much easier to justify its validity when it is based directly on real people. Going forward, we will use this approach to model an entire hospital.
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Affiliation(s)
| | - Michael McCooe
- Improvement Academy, Bradford Royal Infirmary, Bradford, UK
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28
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Chowdhury SR, Lawton T, Akram A, Collin R, Beck J. Citrate versus non-citrate anticoagulation in continuous renal replacement therapy: Results following a change in local critical care protocol. J Intensive Care Soc 2016; 18:47-51. [PMID: 28979536 DOI: 10.1177/1751143716676820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 11/16/2022] Open
Abstract
Continuous renal replacement therapy necessitates the use of anticoagulation. The anticoagulant of choice has traditionally been heparin. Emerging evidence has highlighted the deleterious effects of systemic heparin anticoagulation in the critically ill. Regional citrate anticoagulation has been used as an alternative in the setting of continuous renal replacement therapy. Our retrospective before-and-after cohort study aimed to ascertain if regional citrate anticoagulation is associated with any benefit in terms of circuit longevity, rates of complications, blood transfusion requirements and mortality, when introduced to a large general intensive care unit with a case mix of acute medical patients and acute and elective surgical patients. The switch to regional citrate anticoagulation for continuous renal replacement therapy in our intensive care unit has been associated with a dramatically longer circuit life, with major implications for cost savings in terms of reduced nursing workload. We hope to look at fiscal aspects of the change in protocol in greater depth.
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Affiliation(s)
- Samina R Chowdhury
- West Yorkshire School of Anaesthesia, Yorkshire and The Humber Deanery, Leeds, UK
| | - Tom Lawton
- Department of Anaesthesia and Critical Care, Bradford Royal Infirmary, Bradford, UK
| | - Aaqid Akram
- South Yorkshire School of Anaesthesia, Yorkshire and The Humber Deanery, Sheffield, UK
| | - Robert Collin
- West Yorkshire School of Anaesthesia, Yorkshire and The Humber Deanery, Leeds, UK
| | - James Beck
- Department of Anaesthesia and Critical Care, St. James's University Hospital, Leeds, UK
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Charlesworth M, Lawton T, Fletcher S. Noninvasive positive pressure ventilation for acute respiratory failure following oesophagectomy: Is it safe? A systematic review of the literature. J Intensive Care Soc 2015; 16:215-221. [PMID: 28979413 DOI: 10.1177/1751143715571698] [Citation(s) in RCA: 9] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To find, critically appraise and synthesise all published studies so as to determine the safety and spectrum of use of noninvasive positive pressure ventilation for acute respiratory failure following oesophagectomy. DESIGN Systematic review. METHODS The MEDLINE and EMBASE databases were searched and the quality of the studies and any bias or confounding were rated according to established protocols. Outcomes extracted included re-intubation, anastomotic leakage, length of intensive care unit stay and mortality. The data were analysed quantitatively and qualitatively. Pooling of outcomes was considered if appropriate. RESULTS The search identified four papers, demonstrating the understudying/underreporting of the topic. Three were case-series and one was a conference abstract. The overall methodological quality was low. Design-specific biases and confounding were high. Despite this, the included studies conclude that noninvasive positive pressure ventilation is safe and effective and that re-intubation rates, intensive care unit length of stay, mortality and anastomotic dehiscence is lower when it is used. Meta-analysis was deemed to be inappropriate. CONCLUSIONS Despite the conclusions and consensus of the included studies, there is no evidence to definitively conclude that noninvasive positive pressure ventilation is either safe or dangerous following oesophagectomy and the current literary evidence is inadequate. Current practice varies and is based on opinion and consensus. As such, randomised controlled studies are urgently required as current practice may cause undue harm to patients. The incidence of anastomotic leakage with noninvasive positive pressure ventilation use needs to be determined.
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Affiliation(s)
- Michael Charlesworth
- Department of Anaesthesia, Central Manchester University Hospitals, Manchester, UK
| | - Tom Lawton
- Department of Critical Care, Bradford Royal Infirmary, Bradford, UK
| | - Stephen Fletcher
- Department of Critical Care, Bradford Royal Infirmary, Bradford, UK
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Lawton T, Conway J, Edland S. Remediation of abnormal visual motion processing significantly improves attention, reading fluency, and working memory in dyslexics. J Vis 2014. [DOI: 10.1167/14.10.621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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31
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Sutcliffe M, Lawton T, Hollins T. Awake fibreoptic intubation with high risk of aspiration. Anaesthesia 2011; 66:948. [DOI: 10.1111/j.1365-2044.2011.06850.x] [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: 12/01/2022]
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32
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Lawton T. Direction discrimination training removes timing deficits in the dorsal pathway that impair reading ability. J Vis 2010. [DOI: 10.1167/9.8.821] [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: 11/24/2022] Open
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33
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Lawton T, Cottrell G. Magnocellular Deficits in Dyslexia Provide Evidence Against Noise Exclusion Hypothesis. J Vis 2010. [DOI: 10.1167/10.7.454] [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: 11/24/2022] Open
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34
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Lawton T. Figure/Ground and left-right movement discrimination developing when child is learning to read. J Vis 2010. [DOI: 10.1167/2.7.32] [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: 11/24/2022] Open
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35
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LaRocque R, Rao S, Lawton T, Tsibris A, Schoenfeld D, Barry A, Yanni E, Marano N, Gallagher N, Marano C, Brunette G, Ryan E. Use and sources of medical information among departing international travelers to low and middle income countries at Logan International Airport-Boston, MA, 2009. Int J Infect Dis 2010. [DOI: 10.1016/j.ijid.2010.02.1777] [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: 11/29/2022] Open
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36
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Bevers TB, Armstrong DK, Arun B, Carlson RW, Cowan KH, Daly MB, Fleming I, Garber JE, Gemignani M, Gradishar WJ, Krontiras H, Kulkarni S, Laronga C, Lawton T, Loftus L, Macdonald DJ, Mahoney MC, Merajver SD, Seewaldt V, Sellin RV, Shapiro CL, Singletary E, Ward JH. Breast cancer risk reduction. J Natl Compr Canc Netw 2007; 5:676-701. [PMID: 17927926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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37
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Byerly G, Lawton T, Lunsford V, Patton S, Schiller M, Tabel T, Kehoe B. Keys to developing a high-performance supply chain. Panel discussion. Mater Manag Health Care 2007; 16:49-60. [PMID: 17955937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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38
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Dunnwald L, Gralow J, Ellis G, Livingston R, Linden H, Specht J, Doot R, Lawton T, Barlow W, Mankoff D. Tumor metabolism, blood flow changes, and prognosis by positron emission tomography: A prospective cohort of locally advanced breast cancer patients. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.506] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
506 Background: Breast cancer patients with locally advanced tumors receive preoperative chemotherapy to provide early systemic treatment and assess in-vivo tumor response. Positron emission tomography (PET) has been used to follow tumor response to therapy, as pathologic response is predictive of patient outcome. We evaluated the prognostic utility of serial quantitative PET tumor blood flow (BF) and metabolism measurements. Methods: Fifty-five women with a primary diagnosis of locally advanced breast carcinoma (LABC) underwent dynamic [18F]-FDG and [15O]-water PET scans prior to and at midpoint of neoadjuvant chemotherapy. The FDG metabolic rate (MRFDG), transport (K1), and flux (Ki) parameters were calculated, and tumor blood flow was estimated from the [15O]-water study. Associations between tumor BF and MRFDG measurements and disease-free survival (DFS) and overall survival (OS) were evaluated using the Cox proportional hazards model. Results: Patients that had an increase in BF and K1, from baseline to mid-therapy measurements, had elevated recurrence and mortality risks compared to patients that had reductions in BF and MRFDG values. In multivariate analysis, changes in BF and K1 remained independent prognostic indicators of DFS and OS survival. Conclusions: PET measurements of tumor response prior to completion of neoadjuvant chemotherapy were predictive of patient outcome. Patients that failed to have a decline in BF and K1 experienced higher risks of recurrence and mortality that was largely independent of clinical tumor characteristics assessed in this study. These results suggest that tumor perfusion, measured directly by [15O]-water or indirectly by dynamic FDG PET, is highly predictive of outcome in neoadjuvantly treated breast cancer. No significant financial relationships to disclose.
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Affiliation(s)
- L. Dunnwald
- University of Washington, Seattle, WA; Arizona Cancer Center, Tucson, AZ
| | - J. Gralow
- University of Washington, Seattle, WA; Arizona Cancer Center, Tucson, AZ
| | - G. Ellis
- University of Washington, Seattle, WA; Arizona Cancer Center, Tucson, AZ
| | - R. Livingston
- University of Washington, Seattle, WA; Arizona Cancer Center, Tucson, AZ
| | - H. Linden
- University of Washington, Seattle, WA; Arizona Cancer Center, Tucson, AZ
| | - J. Specht
- University of Washington, Seattle, WA; Arizona Cancer Center, Tucson, AZ
| | - R. Doot
- University of Washington, Seattle, WA; Arizona Cancer Center, Tucson, AZ
| | - T. Lawton
- University of Washington, Seattle, WA; Arizona Cancer Center, Tucson, AZ
| | - W. Barlow
- University of Washington, Seattle, WA; Arizona Cancer Center, Tucson, AZ
| | - D. Mankoff
- University of Washington, Seattle, WA; Arizona Cancer Center, Tucson, AZ
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Lawton T, Cronin J, Drinkwater E, Lindsell R, Pyne D. The effect of continuous repetition training and intra-set rest training on bench press strength and power. J Sports Med Phys Fitness 2004; 44:361-7. [PMID: 15758847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
AIM The purpose of this research was to compare the effects of continuous repetition and intra-set rest training on maximal strength and power output of the upper body. METHODS The 6 repetition maximum (6RM) and bench press throw power output against masses of 20, 30 and 40 kg of 26 elite junior male basketball and soccer players were tested on 2 separate occasions for reliability purposes. Subjects were then randomly assigned to either a continuous repetition (CR - 4 sets x 6 repetitions) or intra-set rest (ISR - 8 sets x 3 repetitions) training regime over 6-weeks. Volume (sets x repetitions x %6RM) between groups was equated and both groups completed all sets in the same time period (13 minutes and 20 seconds). The total concentric work time was determined to identify differences in training regimes. Independent sample t-tests on preintervention and postintervention percentage change scores were analysed for significant differences (p<0.05). RESULTS The observed coefficients of variation (1.7% to 4.8%) and intraclass correlation coefficients (r=0.87 to 0.98) indicated stability of these measures across testing occasions. The CR group significantly increased 6RM strength (9.7%) compared with the ISR group (4.9%). The total concentric work time was significantly longer in CR training than ISR (36.03+/- 4.03 s and 31.74+/-4.71 s; p=0.13). Power output increases across the 20, 30 and 40 kg loads ranged from 5.8% to 10.9% for both training groups but the between-group percentage change scores were not significantly different. CONCLUSIONS Bench press training involving 4 sets of 6 continuous repetitions elicited a greater improvement in bench press strength than 8 sets of 3 repetitions at the same percentage load of their 6RM. Both ISR and CR training were equally effective in increasing power output.
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Affiliation(s)
- T Lawton
- Strength and Conditioning, Australian Institute of Sport, Belconnen ACT, Australia
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Arnold SJ, ApSimon H, Barlow J, Belcher S, Bell M, Boddy JW, Britter R, Cheng H, Clark R, Colvile RN, Dimitroulopoulou S, Dobre A, Greally B, Kaur S, Knights A, Lawton T, Makepeace A, Martin D, Neophytou M, Neville S, Nieuwenhuijsen M, Nickless G, Price C, Robins A, Shallcross D, Simmonds P, Smalley RJ, Tate J, Tomlin AS, Wang H, Walsh P. Introduction to the DAPPLE Air Pollution Project. Sci Total Environ 2004; 332:139-153. [PMID: 15336898 DOI: 10.1016/j.scitotenv.2004.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Revised: 02/01/2004] [Accepted: 04/28/2004] [Indexed: 05/24/2023]
Abstract
The Dispersion of Air Pollution and its Penetration into the Local Environment (DAPPLE) project brings together a multidisciplinary research group that is undertaking field measurements, wind tunnel modelling and computer simulations in order to provide better understanding of the physical processes affecting street and neighbourhood-scale flow of air, traffic and people, and their corresponding interactions with the dispersion of pollutants at street canyon intersections. The street canyon intersection is of interest as it provides the basic case study to demonstrate most of the factors that will apply in a wide range of urban situations. The aims of this paper are to introduce the background of the DAPPLE project, the study design and methodology for data collection, some preliminary results from the first field campaign in central London (28 April-24 May 2003) and the future for this work. Updated information and contact details are available on the web site at http://www.dapple.org.uk.
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Affiliation(s)
- S J Arnold
- Department of Environmental Science and Technology, Royal school of Mines Building (Rm. 4.33), Imperial College London, Prince Consort Rd., South Kensington, London SW7 2BP, UK.
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Lawton T. Training direction selectivity significantly improves reading fluency for all types of inefficient readers. J Vis 2004. [DOI: 10.1167/4.8.765] [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: 11/24/2022] Open
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Budowle B, Masibay A, Anderson SJ, Barna C, Biega L, Brenneke S, Brown BL, Cramer J, DeGroot GA, Douglas D, Duceman B, Eastman A, Giles R, Hamill J, Haase DJ, Janssen DW, Kupferschmid TD, Lawton T, Lemire C, Llewellyn B, Moretti T, Neves J, Palaski C, Schueler S, Sgueglia J, Sprecher C, Tomsey C, Yet D. STR primer concordance study. Forensic Sci Int 2001; 124:47-54. [PMID: 11741760 DOI: 10.1016/s0379-0738(01)00563-1] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Over 1500 population database samples comprising African Americans, Caucasians, Hispanics, Native Americans, Chamorros and Filipinos were typed using the PowerPlex 16 and the Profiler Plus/COfiler kits. Except for the D8S1179 locus in Chamorros and Filipinos from Guam, there were eight examples in which a typing difference due to allele dropout was observed. At the D8S1179 locus in the population samples from Guam, there were 13 examples of allele dropout observed when using the Profiler Plus kit. The data support that the primers used in the PowerPlex 16, Profiler Plus, and COfiler kits are reliable for typing reference samples that are for use in CODIS. In addition, allele frequency databases have been established for the STR loci Penta D and Penta E. Both loci are highly polymorphic.
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Affiliation(s)
- B Budowle
- FBI, Laboratory Division, 935 Pennsylvania Avenue, NW, Washington, DC 20535, USA.
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43
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Chang JH, Vines E, Bertsch H, Fraker DL, Czerniecki BJ, Rosato EF, Lawton T, Conant EF, Orel SG, Schuchter L, Fox KR, Zieber N, Glick JH, Solin LJ. The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer 2001. [PMID: 11283921 DOI: 10.1002/1097-0142(20010401)91:] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Advances in the diagnosis and treatment of breast carcinoma have led to a multidisciplinary approach to management for patients with breast carcinoma. To assess the effect of this approach, the authors performed an evaluation for a cohort of patients examined in a multidisciplinary breast cancer center. METHODS An analysis was performed for the records of 75 consecutive women with 77 breast lesions examined in consultation in a multidisciplinary breast cancer center between January and June 1998. Each patient's case was evaluated by a panel consisting of a medical oncologist, surgical oncologist, radiation oncologist, pathologist, diagnostic radiologist, and, when indicated, plastic surgeon. A comprehensive history and physical examination was performed, and the relevant mammograms, pathology slides, and medical records were reviewed. Treatment recommendations made before this evaluation were compared with the consensus recommendations made by the panel. RESULTS For the 75 patients, the multidisciplinary panel disagreed with the treatment recommendations from the outside physicians in 32 cases (43%), and agreed in 41 cases (55%). Two patients (3%) had no treatment recommendation before consultation. For the 32 patients with a disagreement, the treatment recommendations were breast-conservation treatment instead of mastectomy (n = 13; 41%) or reexcision (n = 2; 6%); further workup instead of immediate definitive treatment (n = 10; 31%); treatment based on major change in diagnosis on pathology review (n = 3; 9%); addition of postmastectomy radiation treatment (n = 3; 9%); or addition of hormonal therapy (n = 1; 3%). CONCLUSIONS The multidisciplinary breast cancer evaluation program provided an integrated program in which individual patients were evaluated by a team of physicians and led to a change in treatment recommendation for 43% (32 of 75) of the patients examined. This multidisciplinary program provided important second opinions for many patients with breast carcinoma.
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Affiliation(s)
- J H Chang
- Department of Radiation Oncology, University of Pennsylvania Cancer Center and School of Medicine, Philadelphia, Pennsylvania, USA
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Chang JH, Vines E, Bertsch H, Fraker DL, Czerniecki BJ, Rosato EF, Lawton T, Conant EF, Orel SG, Schuchter L, Fox KR, Zieber N, Glick JH, Solin LJ. The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer 2001; 91:1231-7. [PMID: 11283921 DOI: 10.1002/1097-0142(20010401)91:7<1231::aid-cncr1123>3.0.co;2-k] [Citation(s) in RCA: 242] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Advances in the diagnosis and treatment of breast carcinoma have led to a multidisciplinary approach to management for patients with breast carcinoma. To assess the effect of this approach, the authors performed an evaluation for a cohort of patients examined in a multidisciplinary breast cancer center. METHODS An analysis was performed for the records of 75 consecutive women with 77 breast lesions examined in consultation in a multidisciplinary breast cancer center between January and June 1998. Each patient's case was evaluated by a panel consisting of a medical oncologist, surgical oncologist, radiation oncologist, pathologist, diagnostic radiologist, and, when indicated, plastic surgeon. A comprehensive history and physical examination was performed, and the relevant mammograms, pathology slides, and medical records were reviewed. Treatment recommendations made before this evaluation were compared with the consensus recommendations made by the panel. RESULTS For the 75 patients, the multidisciplinary panel disagreed with the treatment recommendations from the outside physicians in 32 cases (43%), and agreed in 41 cases (55%). Two patients (3%) had no treatment recommendation before consultation. For the 32 patients with a disagreement, the treatment recommendations were breast-conservation treatment instead of mastectomy (n = 13; 41%) or reexcision (n = 2; 6%); further workup instead of immediate definitive treatment (n = 10; 31%); treatment based on major change in diagnosis on pathology review (n = 3; 9%); addition of postmastectomy radiation treatment (n = 3; 9%); or addition of hormonal therapy (n = 1; 3%). CONCLUSIONS The multidisciplinary breast cancer evaluation program provided an integrated program in which individual patients were evaluated by a team of physicians and led to a change in treatment recommendation for 43% (32 of 75) of the patients examined. This multidisciplinary program provided important second opinions for many patients with breast carcinoma.
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Affiliation(s)
- J H Chang
- Department of Radiation Oncology, University of Pennsylvania Cancer Center and School of Medicine, Philadelphia, Pennsylvania, USA
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Abstract
Sensitivity encoding (SENSE) was used to improve the performance of three-dimensional contrast-enhanced magnetic resonance angiography (3D CE-MRA). Utilizing an array of receiver coils for sensitivity encoding, the encoding efficiency of gradient-echo imaging was increased by factors of up to three. The feasibility of the approach was demonstrated for imaging of the abdominal vasculature. On the one hand, using a SENSE reduction factor of two, the spatial resolution of a breath-hold scan of 17 seconds was improved to 1.0 x 2.0 x 2.0 mm(3). On the other hand, using threefold reduction, time-resolved 3D CE-MRA was performed with a true temporal resolution of 4 seconds, at a spatial resolution of 1.6 x 2.1 x 4.0 mm(3). CE-MRA with SENSE was performed in healthy volunteers and patients and compared with a standard protocol. Throughout, diagnostic quality images were obtained, showing the ability of sensitivity encoding to enhance spatial and/or temporal resolution considerably in clinical angiographic examinations.
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Affiliation(s)
- M Weiger
- Institute of Biomedical Engineering, University of Zurich and Swiss Federal Institute of Technology Zurich, CH-8092 Zurich, Switzerland
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Bedrosian I, Reynolds C, Mick R, Callans LS, Grant CS, Donohue JH, Farley DR, Heller R, Conant E, Orel SG, Lawton T, Fraker DL, Czerniecki BJ. Accuracy of sentinel lymph node biopsy in patients with large primary breast tumors. Cancer 2000; 88:2540-5. [PMID: 10861431 DOI: 10.1002/1097-0142(20000601)88:11<2540::aid-cncr16>3.0.co;2-a] [Citation(s) in RCA: 148] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with large breast tumors are increasingly undergoing neoadjuvant treatment to downstage local disease; however, accurate staging of the axilla before the initiation of chemotherapy remains problematic. In the current study, the authors report on the accuracy of sentinel lymph node (SLN) biopsy in such patients to determine the feasibility of applying this technique before induction chemotherapy. METHODS One hundred three patients with 104 tumors classified as American Joint Committee on Cancer (AJCC) T2 (tumor >/= 2 cm but </= 5 cm) or larger were recruited at the University of Pennsylvania and the Mayo Clinic. In the majority of cases, combined blue dye and radiotracer was used for SLN identification. After SLN identification, a completion axillary lymph node dissection was performed in 87 cases. The SLN was evaluated with hematoxylin and eosin and immunohistochemistry. RESULTS The SLN was identified in 99% of cases. The overall rate of lymph node metastasis was 59% (95% exact confidence interval [95% CI], 49-68%) (61 of 104 cases). The SLN false-negative rate was 2% (95% exact CI, < 1-11.5%) (2 patients). In 56 tumors >/= 3 cm, 1 false-negative result (2% [95% exact CI, < 1-15%]) was identified, and the rate of lymph node metastasis was 62.5% (95% exact CI, 48. 5-75%) (35 of 56 tumors). Within 30 SLN positive patients with tumors >/= 3 cm and complete axillary lymph node dissection, 3 of 8 patients (37.5% [95% exact CI, 8.5-75.5%]) with micrometastasis (</= 2 mm) to the SLN had positive non-SLN compared with 21 of 22 patients (95.5% [95% exact CI, 77-100%]) with macrometastasis (> 2 mm) to the SLN (P = 0.002). CONCLUSIONS SLN biopsy for patients with large breast tumors is technically feasible and highly accurate. SLN biopsy should be considered for the staging of clinically negative axilla in patients scheduled to receive neoadjuvant chemotherapy.
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Affiliation(s)
- I Bedrosian
- Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104, USA
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Carmeci C, deConinck EC, Lawton T, Bloch DA, Weigel RJ. Analysis of estrogen receptor messenger RNA in breast carcinomas from archival specimens is predictive of tumor biology. Am J Pathol 1997; 150:1563-70. [PMID: 9137083 PMCID: PMC1858204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
As the size of breast tumors continues to decrease, it has become more difficult to obtain adequate tumor tissue for molecular studies. We have used the estrogen receptor (ER) gene as a model to study the ability to perform a quantitative analysis of ER mRNA extracted from archival breast carcinoma specimens using reverse transcriptase polymerase chain reaction. Based upon ER mRNA abundance, tumors were characterized as having low, medium, or high ER mRNA expression. These data were compared with ER and progesterone receptor (PR) status determined by enzyme immunoassay, tumor histology, and Bloom-Richardson grade. Comparing the low and high ER mRNA groups, there were statistically significant differences in ER-positive status (10% versus 95%; P = 0.0001), PR-positive status (10% versus 90%; P = 0.0001), and tumor grade (2.67 +/- 0.12 versus 2.09 +/- 0.14; P = 0.0025). Of the 28 tumors in the high ER mRNA group, 5 (18%) were invasive lobular carcinomas whereas all 24 tumors with low ER mRNA were invasive ductal carcinomas. These data demonstrate that archival breast tumor specimens can be characterized for ER mRNA abundance. In addition, we conclude that the mechanisms regulating ER gene transcription influence the phenotype of breast carcinomas. These results also suggest that this technique can be designed to provide a quantitative analysis of gene expression for any gene of interest utilizing archival tumor specimens.
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Affiliation(s)
- C Carmeci
- Department of Surgery, Stanford University, CA 94305, USA
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Yin W, Smiley E, Germiller J, Sanguineti C, Lawton T, Pereira L, Ramirez F, Bonadio J. Primary structure and developmental expression of Fbn-1, the mouse fibrillin gene. J Biol Chem 1995; 270:1798-806. [PMID: 7829516 DOI: 10.1074/jbc.270.4.1798] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Previous studies have reported > 10 kilobases of human fibrillin-1 cDNA sequence, but a consensus regarding the 5' end of the transcript remains to be worked out. One approach to developing a clear consensus would be to search for regions of evolutionary conservation in transcripts from a related species such as mouse. As reported here, the mouse fibrillin-1 transcript encodes a highly conserved polypeptide of 2,871 amino acids. The upstream sequence that flanks the ATG is considerably less well conserved, however. Indeed, the ATG codon (which occurs in the context of a Kozak consensus sequence and is located just upstream of a consensus signal peptide) signals the point where human and mouse fibrillin-1 sequences cease to be nearly identical. Together, these results are consistent with previous efforts by Pereira et al. (Pereira, L., D'Alessio, M., Ramirez, F., Lynch, J. R., Sykes, B., Pangilinan, T., and Bonadio, J. (1993) Human Mol. Genet. 2, 961-968) to identify the human fibrillin-1 translational start site. Sequences immediately upstream of the ATG are GC-rich and devoid of TATA and CCAAT boxes, which suggests that the mouse fibrillin-1 gene will be broadly expressed. A survey of expression in mouse embryo tissues is consistent with this hypothesis and suggests two novel functions for fibrillin-associated microfibrils in non-elastic connective tissues.
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Affiliation(s)
- W Yin
- Department of Pathology, University of Michigan, Ann Arbor 48109-0650
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Araten DJ, Lawton T, Ferrara J, Antin JH, Milford E, Carpenter CB, Maziarz RT. In vitro alloreactivity against host antigens in an adult HLA-mismatched bone marrow transplant recipient despite in vivo host tolerance. Transplantation 1993; 55:76-82. [PMID: 8420068 DOI: 10.1097/00007890-199301000-00015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
An adult recipient of an HLA-DR, DQ-mismatched, T cell-depleted bone marrow graft, who remains without graft versus host disease and who is not maintained on immunosuppressive therapy, was studied at 23 months posttransplantation for in vitro reactivity against the mismatched antigens of the host. The donor's PBMC's proliferated vigorously against the recipient's stimulators in the pretransplant mixed lymphocyte cultures (MLC). After transplant reconstitution, MLCs demonstrated that the in vitro response of engrafted donor T cells against host MHC class II antigens was equivalent to control allogeneic responses, while there was no detectable response against the donor's antigens. Posttransplantation limiting dilution analysis showed no difference between the precursor frequencies of antihost responders among populations of fresh donor PBMCs and among the engrafted cells of donor origin that are found circulating in the patient. This result suggests that clonal deletion is, at best, incomplete and that peripheral tolerance is essential in protecting this patient from GVHD. These findings also support the conclusion that bone marrow-derived thymic elements may be important for clonal deletion in human chimeras.
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Affiliation(s)
- D J Araten
- Hematology Division, Brigham and Women's Hospital, Boston, Massachusetts
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Wong M, Lawton T, Goetinck PF, Kuhn JL, Goldstein SA, Bonadio J. Aggrecan core protein is expressed in membranous bone of the chick embryo. Molecular and biomechanical studies of normal and nanomelia embryos. J Biol Chem 1992; 267:5592-8. [PMID: 1372006] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
The recessive mutation nanomelia blocks the synthesis of a large aggregating proteoglycan (aggrecan) by avian embryo chondrocytes. Lack of aggrecan is associated with short stature, multiple morphological defects in cartilage, and embryo lethality. Bony defects have also been described, but were assumed to be a secondary consequence of the cartilage defect. However, two lines of evidence presented in this paper indicate that the aggrecan deficiency directly affects intramembranous bone. First, the morphology (i.e. projected area and shape) of certain membranous bones of nanomelia embryos was abnormal. Second, membranous bone from nanomelia embryos proved to be significantly stiffer in biomechanical tests that measured functional properties of the extracellular matrix. These findings were unexpected because intramembranous bones normally develop from mesenchyme and not from a cartilage intermediate, and they prompted a search for evidence of aggrecan expression in the bone of normal chick embryos. We report that: 1) aggrecan mRNA was identified by PCR analysis of total RNA isolated from day-13 chick embryo calvarium, 2) the PCR method successfully amplified aggrecan mRNA from primary chick embryo osteoblasts in culture, 3) in situ hybridization of membranous bone tissue sections demonstrated aggrecan expression by chick embryo osteoblasts in vivo, and 4) the aggrecan message was identified in Northern blots of calvarial mRNA probed at high stringency. The results of the molecular and biomechanical studies provide evidence that aggrecan is indeed expressed in membranous bone as well as cartilage. Altogether, these results suggest that aggrecan may contribute to the functional properties and the normal growth and development of avian membranous bone.
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Affiliation(s)
- M Wong
- Department of Surgery, University of Michigan, Ann Arbor 48109-0650
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