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Joseph AP, Newey A, Glover A, Mohabbat W. An unusual case of a penetrating neck injury (PNI) illustrating the use of a "no zone" approach for the management of this injury and a review of the literature. Trauma Case Rep 2021; 32:100402. [PMID: 33644288 PMCID: PMC7892993 DOI: 10.1016/j.tcr.2021.100402] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 11/29/2022] Open
Abstract
We present an unusual case of a young male with a penetrating neck injury (PNI) due to a work-related injury. A metallic foreign body traversed from entry at surgical Zone 2 to Zone 1 in the neck and resulted in a transection of the left thyrocervical trunk at the origin with the left subclavian artery. Computed Tomographic Angiography (CTA) of the aortic arch and major branch vessels demonstrated haemorrhage anterior to the left subclavian artery and left thyrocervical trunk. We describe some of the diagnostic and operative challenges which may occur in these rare and life-threatening injuries. We have also reviewed some of the recent key literature on this topic and have collated the recommendations of the review. In recent years, there has been a movement away from selective “zone-based” mandatory surgical exploration for Zone 2 injuries, as well as invasive and time-consuming investigations (such as digital subtraction angiography, contrast oesophageal swallow and bronchoscopy) for Zone 1 and 3 injuries due to the high number of negative surgical procedures and investigations. We demonstrate there is now an evidence-based algorithm which demonstrates that a “no zone” approach to the management of these patients is safe and effective. This requires an initial physical examination looking for the presence or absence of “hard”, “soft” or “no” physical signs in these patients, and then deciding on subsequent management which would include immediate surgery, CTA of the aortic arch and branches (and subsequent surgical or other management) or observation only. Our aim in describing this case it to highlight that there is now good evidence-based guidance for the safe and effective management of patients with this infrequent but potentially fatal injury.
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Affiliation(s)
- A P Joseph
- Emergency Department and Trauma Service, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - A Newey
- Radiology Department, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - A Glover
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - W Mohabbat
- Department of Vascular Surgery, Royal North Shore Hospital, St Leonards, NSW 2056, Australia
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Swan F, Newey A, Bland M, Allgar V, Booth S, Bausewein C, Yorke J, Johnson M. Airflow relieves chronic breathlessness in people with advanced disease: An exploratory systematic review and meta-analyses. Palliat Med 2019; 33:618-633. [PMID: 30848701 DOI: 10.1177/0269216319835393] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Chronic breathlessness is a neglected symptom of advanced diseases. AIM To examine the effect of airflow for chronic breathlessness relief. DESIGN Exploratory systematic review and meta-analysis. DATA SOURCES Medline, CINAHL, AMED and Cochrane databases were searched (1985-2018) for observational studies or randomised controlled trials of airflow as intervention or comparator. Selection against predefined inclusion criteria, quality appraisal and data extraction was conducted by two independent reviewers with access to a third for unresolved differences. 'Before and after' breathlessness measures from airflow arms were analysed. Meta-analysis was carried out where possible. RESULTS In all, 16 of 78 studies (n = 929) were included: 11 randomised controlled trials of oxygen versus medical air, 4 randomised controlled trials and 1 fan cohort study. Three meta-analyses were possible: (1) Fan at rest in three studies (n = 111) offered significant benefit for breathlessness intensity (0-100 mm visual analogue scale and 0-10 numerical rating scale), mean difference -11.17 (95% confidence intervals (CI) -16.60 to -5.74), p = 0.06 I2 64%. (2) Medical air via nasal cannulae at rest in two studies (n = 89) improved breathlessness intensity (visual analogue scale), mean difference -12.0 mm, 95% CI -7.4 to -16.6, p < 0.0001 I2 = 0%. (3) Medical airflow during a constant load exercise test before and after rehabilitation (n = 29) in two studies improved breathlessness intensity (modified Borg scale, 0-10), mean difference -2.9, 95% CI -3.2 to -2.7, p < 0.0001 I2 = 0%. CONCLUSION Airflow appears to offer meaningful relief of chronic breathlessness and should be considered as an adjunct treatment in the management of breathlessness.
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Affiliation(s)
- Flavia Swan
- 1 Wolfson Palliative Care Research Centre, Institute for Clinical and Applied Health Research, Hull York Medical School (HYMS), University of Hull, Hull, UK
| | - Alison Newey
- 2 Community Palliative Care, Withington Community Hospital, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Martin Bland
- 3 Department of Health Sciences, University of York, York, UK
| | - Victoria Allgar
- 3 Department of Health Sciences, University of York, York, UK
| | - Sara Booth
- 4 Department of Oncology, University of Cambridge, Cambridge, UK
| | - Claudia Bausewein
- 5 Department of Palliative Medicine, Munich University Hospital, München, Germany
| | - Janelle Yorke
- 6 Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK.,7 Christie Patient Centred Research Group (CPCR), The Christie NHS Foundation Trust, Manchester, UK
| | - Miriam Johnson
- 1 Wolfson Palliative Care Research Centre, Institute for Clinical and Applied Health Research, Hull York Medical School (HYMS), University of Hull, Hull, UK
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Back M, Jayamanne D, Brazier D, Newey A, Bailey D, Schembri G, Hsiao E, Khasraw M, Wong M, Kastelan M, Brown C, Wheeler H. Pattern of failure in anaplastic glioma patients with an IDH1/2 mutation. Strahlenther Onkol 2019; 196:31-39. [PMID: 31028406 DOI: 10.1007/s00066-019-01467-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 03/29/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE The current study aimed to assess patterns of failure (PoF) in anaplastic glioma (AG) patients managed with intensity-modulated radiation therapy (IMRT) and their relationship to molecular subtype. METHODS The outcomes of AG patients managed between 2008 and 2014 and entered into a prospective database were assessed, including PoF. AG was initially defined using the WHO 2007 classification, but for analysis, patients were subsequently recategorised based on WHO 2016 as anaplastic oligodendroglioma (AOD), astrocytoma isocitrate dehydrogenase (IDH) mutant (AAmut) or astrocytoma IDH wildtype (AAwt). Management involved IMRT and temozolomide (TMZ), including from 2011 patients with an IDH mutation (IDHmut) planned with 18F-fluoroethyltyrosine (FET) and 18F-fluorodeoxyglucose (FDG) positron-emission tomography (PET). PoF was local, marginal or distant in relation to the IMRT volume. Relapse-free survival (RFS) was calculated from the start of IMRT. RESULTS A total of 156 patients were assessed, with median follow-up of 5.1 years. Of these patients, 75% were IDHmut, 44% were managed at first or later relapse and 73% received TMZ. Relapse occurred in 68 patients, with 6‑year RFS of 75.0, 48.8 and 2.5% for AOD, AAmut and AAwt, respectively (p < 0.001). There was a component of local relapse in 63%, of marginal relapse in 19% and of distant relapse in 37% of relapses. Isolated local, marginal and distant relapse was evident in 51, 9 and 22%, respectively. A distant relapse pattern was more frequent in IDHmut compared to IDHwt patients (26% vs. 45%, p = 0.005), especially within the first 2 years post-IMRT. In multivariate analysis, distant relapse remained associated with AAmut (p < 0.002) and delayed IMRT until the second relapse (p < 0.001). CONCLUSION Although patients with IDH-mutated AG have improved outcomes, there was a higher proportion of distant relapses occurring during the 2 years after IMRT.
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Affiliation(s)
- M Back
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards Sydney NSW 2065, Sydney, Australia.
- Central Coast Cancer Centre, Gosford Hospital, Gosford, Australia.
- Genesis Cancer Care, Sydney, Australia.
- Sydney Medical School, University of Sydney, Sydney, Australia.
- The Brain Cancer Group, Sydney, Australia.
| | - D Jayamanne
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards Sydney NSW 2065, Sydney, Australia
- Central Coast Cancer Centre, Gosford Hospital, Gosford, Australia
| | - D Brazier
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards Sydney NSW 2065, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - A Newey
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards Sydney NSW 2065, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - D Bailey
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, Australia
- Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - G Schembri
- The Brain Cancer Group, Sydney, Australia
| | - E Hsiao
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, Australia
| | - M Khasraw
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards Sydney NSW 2065, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- The Brain Cancer Group, Sydney, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - M Wong
- Central Coast Cancer Centre, Gosford Hospital, Gosford, Australia
| | - M Kastelan
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards Sydney NSW 2065, Sydney, Australia
- The Brain Cancer Group, Sydney, Australia
| | - C Brown
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards Sydney NSW 2065, Sydney, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - H Wheeler
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards Sydney NSW 2065, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- The Brain Cancer Group, Sydney, Australia
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Back M, Jayamanne DT, Brazier D, Newey A, Bailey D, Schembri GP, Hsiao E, Khasraw M, Wong M, Kastelan M, Guo L, Clarke S, Wheeler H. Influence of molecular classification in anaplastic glioma for determining outcome and future approach to management. J Med Imaging Radiat Oncol 2019; 63:272-280. [PMID: 30677248 DOI: 10.1111/1754-9485.12850] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 12/07/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Assess survival of patients with anaplastic glioma (AG) and the relationship to molecular subtype. METHODS Patients with AG managed with IMRT between 2008 and 2014 were entered into a prospective database assessing relapse-free survival (RFS) and overall survival (OS). Isocitrate dehydrogenase (IDH) mutations were assessed prospectively from 2011, and subsequent testing of historical patients allowing categorisation under WHO 2016 classification as anaplastic astrocytoma IDH wild type (AAwt), anaplastic astrocytoma IDH mutated (AAmut), anaplastic oligodendroglioma (AOD) or other glial tumour (OTH). Kaplan-Meier estimates of survival distribution were calculated for the primary endpoint of overall survival and Log-rank test used to determine associated factors. RESULTS One hundred and fifty-six patients were included with median follow-up for survivors of 4.7 years. Fifty-six per cent were managed after initial diagnosis, whilst 18% received IMRT at second or later relapse. Seventy-three per cent had temozolomide as part of initial therapy. A total of 118 or 75% of patients had IDH mutated glioma, of which 61 were AOD and 57 AAmut. There were 68 relapses and 52 deaths for a 6yrRFS of 51.2% and 6yrOS of 62.5%. AAwt was associated with worse survival (P < 0.001); and delay of RT until second or later relapse (P = 0.03). Within the 118 patients with IDH mutated tumours, 6yrOS for AOD and AAmut were 90.0% and 62.5%, respectively (P = 0.003). Also two or more craniotomies (P < 0.001), delayed RT (P = 0.006) and age <40 years (P = 0.022) were associated with worse survival on univariate analysis but only AAmut subtype and number of craniotomies on multivariate analysis. CONCLUSION Within AG, molecular classification predicts for survival, and should influence current decision-making.
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Affiliation(s)
- Michael Back
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Central Coast Cancer Centre, Gosford Hospital, Gosford, New South Wales, Australia.,Genesis Cancer Care, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,The Brain Cancer Group, Sydney, New South Wales, Australia
| | - Dasantha T Jayamanne
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - David Brazier
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Alison Newey
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Dale Bailey
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Geoffrey P Schembri
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Edward Hsiao
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Mustafa Khasraw
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,The Brain Cancer Group, Sydney, New South Wales, Australia
| | - Matthew Wong
- Central Coast Cancer Centre, Gosford Hospital, Gosford, New South Wales, Australia
| | - Marina Kastelan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,The Brain Cancer Group, Sydney, New South Wales, Australia
| | - Linxin Guo
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Stephen Clarke
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Helen Wheeler
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,The Brain Cancer Group, Sydney, New South Wales, Australia
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Back M, Jayamanne D, Brazier D, Newey A, Schembri G, Guo L, Wheeler H. Predicting patterns of failure in temporal lobe glioblastoma multiforme: Implications for novel radiation therapy target volume protocols. Eur J Cancer 2016. [DOI: 10.1016/j.ejca.2016.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hopkinson N, Wallis C, Higgins B, Gaduzo S, Sherrington R, Keilty S, Stern M, Britton J, Bush A, Moxham J, Sylvester K, Griffiths V, Sutherland T, Crossingham I, Raju R, Spencer C, Safavi S, Deegan P, Seymour J, Hickman K, Hughes J, Wieboldt J, Shaheen F, Peedell C, Mackenzie N, Nicholl D, Jolley C, Crooks G, Crooks G, Dow C, Deveson P, Bintcliffe O, Gray B, Kumar S, Haney S, Docherty M, Thomas A, Chua F, Dwarakanath A, Summers G, Prowse K, Lytton S, Ong YE, Graves J, Banerjee T, English P, Leonard A, Brunet M, Chaudhry N, Ketchell RI, Cummings N, Lebus J, Sharp C, Meadows C, Harle A, Stewart T, Parry D, Templeton-Wright S, Moore-Gillon J, Stratford- Martin J, Saini S, Matusiewicz S, Merritt S, Dowson L, Satkunam K, Hodgson L, Suh ES, Durrington H, Browne E, Walters N, Steier J, Barry S, Griffiths M, Hart N, Nikolic M, Berry M, Thomas A, Miller J, McNicholl D, Marsden P, Warwick G, Barr L, Adeboyeku D, Mohd Noh MS, Griffiths P, Davies L, Quint J, Lyall R, Shribman J, Collins A, Goldman J, Bloch S, Gill A, Man W, Christopher A, Yasso R, Rajhan A, Shrikrishna D, Moore C, Absalom G, Booton R, Fowler RW, Mackinlay C, Sapey E, Lock S, Walker P, Jha A, Satia I, Bradley B, Mustfa N, Haqqee R, Thomas M, Patel A, Redington A, Pillai A, Keaney N, Fowler S, Lowe L, Brennan A, Morrison D, Murray C, Hankinson J, Dutta P, Maddocks M, Pengo M, Curtis K, Rafferty G, Hutchinson J, Whitfield R, Turner S, Breen R, Naveed SUN, Goode C, Esterbrook G, Ahmed L, Walker W, Ford D, Connett G, Davidson P, Elston W, Stanton A, Morgan D, Myerson J, Maxwell D, Harrris A, Parmar S, Houghton C, Winter R, Puthucheary Z, Thomson F, Sturney S, Harvey J, Haslam PL, Patel I, Jennings D, Range S, Mallia-Milanes B, Collett A, Tate P, Russell R, Feary J, O'Driscoll R, Eaden J, Round J, Sharkey E, Montgomery M, Vaughan S, Scheele K, Lithgow A, Partridge S, Chavasse R, Restrick L, Agrawal S, Abdallah S, Lacy-Colson A, Adams N, Mitchell S, Haja Mydin H, Ward A, Denniston S, Steel M, Ghosh D, Connellan S, Rigge L, Williams R, Grove A, Anwar S, Dobson L, Hosker H, Stableforth D, Greening N, Howell T, Casswell G, Davies S, Tunnicliffe G, Mitchelmore P, Phitidis E, Robinson L, Prowse K, Bafadhel M, Robinson G, Boland A, Lipman M, Bourke S, Kaul S, Cowie C, Forrest I, Starren E, Burke H, Furness J, Bhowmik A, Everett C, Seaton D, Holmes S, Doe S, Parker S, Graham A, Paterson I, Maqsood U, Ohri C, Iles P, Kemp S, Iftikhar A, Carlin C, Fletcher T, Emerson P, Beasley V, Ramsay M, Buttery R, Mungall S, Crooks S, Ridyard J, Ross D, Guadagno A, Holden E, Coutts I, Cullen K, O'Connor S, Barker J, Sloper K, Watson J, Smith P, Anderson P, Brown L, Nyman C, Milburn H, Clive A, Serlin M, Bolton C, Fuld J, Powell H, Dayer M, Woolhouse I, Georgiadi A, Leonard H, Dodd J, Campbell I, Ruiz G, Zurek A, Paton JY, Malin A, Wood F, Hynes G, Connell D, Spencer D, Brown S, Smith D, Cooper D, O'Kane C, Hicks A, Creagh-Brown B, Lordan J, Nickol A, Primhak R, Fleming L, Powrie D, Brown J, Zoumot Z, Elkin S, Szram J, Scaffardi A, Marshall R, Macdonald I, Lightbody D, Farmer R, Wheatley I, Radnan P, Lane I, Booth A, Tilbrook S, Capstick T, Hewitt L, McHugh M, Nelson C, Wilson P, Padmanaban V, White J, Davison J, O'Callaghan U, Hodson M, Edwards J, Campbell C, Ward S, Wooler E, Ringrose E, Bridges D, Long A, Parkes M, Clarke S, Allen B, Connelly C, Forster G, Hoadley J, Martin K, Barnham K, Khan K, Munday M, Edwards C, O'Hara D, Turner S, Pieri-Davies S, Ford K, Daniels T, Wright J, Towns R, Fern K, Butcher J, Burgin K, Winter B, Freeman D, Olive S, Gray L, Pye K, Roots D, Cox N, Davies CA, Wicker J, Hilton K, Lloyd J, MacBean V, Wood M, Kowal J, Downs J, Ryan H, Guyatt F, Nicoll D, Lyons E, Narasimhan D, Rodman A, Walmsley S, Newey A, Buxton M, Dewar M, Cooper A, Reilly J, Lloyd J, Macmillan AB, Roots D, Olley A, Voase N, Martin S, McCarvill I, Christensen A, Agate R, Heslop K, Timlett A, Hailes K, Davey C, Pawulska B, Lane A, Ioakim S, Hough A, Treharne J, Jones H, Winter-Burke A, Miller L, Connolly B, Bingham L, Fraser U, Bott J, Johnston C, Graham A, Curry D, Sumner H, Costello CA, Bartoszewicz C, Badman R, Williamson K, Taylor A, Purcell H, Barnett E, Molloy A, Crawfurd L, Collins N, Monaghan V, Mir M, Lord V, Stocks J, Edwards A, Greenhalgh T, Lenney W, McKee M, McAuley D, Majeed A, Cookson J, Baker E, Janes S, Wedzicha W, Lomas Dean D, Harrison B, Davison T, Calverley P, Wilson R, Stockley R, Ayres J, Gibson J, Simpson J, Burge S, Warner J, Lenney W, Thomson N, Davies P, Woodcock A, Woodhead M, Spiro S, Ormerod L, Bothamley G, Partridge M, Shields M, Montgomery H, Simonds A, Barnes P, Durham S, Malone S, Arabnia G, Olivier S, Gardiner K, Edwards S. Children must be protected from the tobacco industry's marketing tactics. BMJ 2013; 347:f7358. [PMID: 24324220 DOI: 10.1136/bmj.f7358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Nicholas Hopkinson
- British Thoracic Society Chronic Obstructive Pulmonary Disease Specialist Advisory Group, National Heart and Lung Institute, Imperial College, London SW3 6NP, UK
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Newey A. Research with people: Theories, plans and practicals. Counselling and Psychotherapy Research 2011. [DOI: 10.1080/14733145.2011.602929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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