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Bowman EML, Sweeney AM, McAuley DF, Cardwell C, Kane J, Badawi N, Jahan N, Iqbal HK, Mitchell C, Ballantyne JA, Cunningham EL. Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review. Age Ageing 2024; 53:afae077. [PMID: 38640126 PMCID: PMC11028403 DOI: 10.1093/ageing/afae077] [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: 11/20/2023] [Revised: 03/06/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVES Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults. METHODS Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed. RESULTS These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition. CONCLUSIONS The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Aoife M Sweeney
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Danny F McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Chris Cardwell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Joseph Kane
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nadine Badawi
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nusrat Jahan
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Halla Kiyan Iqbal
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Callum Mitchell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Jessica A Ballantyne
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Emma L Cunningham
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
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Coyle V, Forde C, McAuley DF, Wilson RH, Clarke M, Plummer R, Grayson M, McDowell C, Agus A, Doran A, Thomas AL, Barnes RA, Adams R, Chau I, Storey D, McMullan R. Early switch to oral antibiotic therapy in patients with low-risk neutropenic sepsis (EASI-SWITCH): a randomized non-inferiority trial. Clin Microbiol Infect 2024; 30:92-99. [PMID: 37517522 DOI: 10.1016/j.cmi.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES To determine whether early switch to oral antibiotic treatment in adults with neutropenic sepsis at low risk of complications is non-inferior to switching later. METHODS This non-inferiority, parallel-group, randomized, open-label clinical trial enrolled UK adults hospitalized with neutropenic sepsis. Participants were randomly assigned to either switch to oral ciprofloxacin plus co-amoxiclav within 12-24 hours or to continue intravenous treatment for at least 48 hours. The primary outcome was a composite measure of treatment failure, 14 days after randomization. The non-inferiority margin was 15%. RESULTS There were 129 participants from 16 centres and 125 were assessed for the primary outcome. Of these, 113 patients completed protocolized treatment and comprised the per-protocol population. In total, 9 (14.1%) of 64 patients in the standard care arm met the primary end point, compared with 15 (24.6%) of 61 in the early switch arm, giving a risk difference of 10.5% (1-sided 95% CI, -∞% to 22%; p 0.14). In the per-protocol population, 8 (13.3%) of the 60 patients in the standard care arm met the primary end point, compared with 9 (17%) of 53 in the intervention arm giving a risk difference of 3.7% (one-sided 95% CI, -∞% to 14.8%; p 0.59). Duration of hospital stay was shorter in the intervention arm (median 2 [inter-quartile range (IQR) 2-3] vs. 3 days [IQR 2-4]; p 0.002). DISCUSSION Although non-inferiority of early oral switch was found in the per-protocol population, the intervention was not non-inferior in the intent-to-treat population.
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Affiliation(s)
- Vicky Coyle
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Caroline Forde
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Danny F McAuley
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Richard H Wilson
- Translational Research Centre, University of Glasgow, Glasgow, UK
| | - Mike Clarke
- Northern Ireland Methodology Hub, Queen's University Belfast, Belfast, UK; Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Ruth Plummer
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | | | - Cliona McDowell
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Annmarie Doran
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Anne L Thomas
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Rosemary A Barnes
- Cardiff University School of Medicine, Centre for Trials Research, Cardiff, UK
| | - Richard Adams
- Cardiff University School of Medicine, Centre for Trials Research, Cardiff, UK; Velindre NHS Trust, Department of medical oncology, Cardiff, UK
| | - Ian Chau
- The Royal Marsden NHS Foundation Trust, Gastrointestinal and lymphoma unit, London, UK
| | - Dawn Storey
- The Beatson West of Scotland Cancer Centre, Department of medical oncology, Glasgow, UK
| | - Ronan McMullan
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK.
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Matthay MA, Arabi Y, Arroliga AC, Bernard G, Bersten AD, Brochard LJ, Calfee CS, Combes A, Daniel BM, Ferguson ND, Gong MN, Gotts JE, Herridge MS, Laffey JG, Liu KD, Machado FR, Martin TR, McAuley DF, Mercat A, Moss M, Mularski RA, Pesenti A, Qiu H, Ramakrishnan N, Ranieri VM, Riviello ED, Rubin E, Slutsky AS, Thompson BT, Twagirumugabe T, Ware LB, Wick KD. A New Global Definition of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:37-47. [PMID: 37487152 PMCID: PMC10870872 DOI: 10.1164/rccm.202303-0558ws] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [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: 03/20/2023] [Accepted: 07/24/2023] [Indexed: 07/26/2023] Open
Abstract
Background: Since publication of the 2012 Berlin definition of acute respiratory distress syndrome (ARDS), several developments have supported the need for an expansion of the definition, including the use of high-flow nasal oxygen, the expansion of the use of pulse oximetry in place of arterial blood gases, the use of ultrasound for chest imaging, and the need for applicability in resource-limited settings. Methods: A consensus conference of 32 critical care ARDS experts was convened, had six virtual meetings (June 2021 to March 2022), and subsequently obtained input from members of several critical care societies. The goal was to develop a definition that would 1) identify patients with the currently accepted conceptual framework for ARDS, 2) facilitate rapid ARDS diagnosis for clinical care and research, 3) be applicable in resource-limited settings, 4) be useful for testing specific therapies, and 5) be practical for communication to patients and caregivers. Results: The committee made four main recommendations: 1) include high-flow nasal oxygen with a minimum flow rate of ⩾30 L/min; 2) use PaO2:FiO2 ⩽ 300 mm Hg or oxygen saturation as measured by pulse oximetry SpO2:FiO2 ⩽ 315 (if oxygen saturation as measured by pulse oximetry is ⩽97%) to identify hypoxemia; 3) retain bilateral opacities for imaging criteria but add ultrasound as an imaging modality, especially in resource-limited areas; and 4) in resource-limited settings, do not require positive end-expiratory pressure, oxygen flow rate, or specific respiratory support devices. Conclusions: We propose a new global definition of ARDS that builds on the Berlin definition. The recommendations also identify areas for future research, including the need for prospective assessments of the feasibility, reliability, and prognostic validity of the proposed global definition.
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Affiliation(s)
- Michael A. Matthay
- Department of Medicine
- Department of Anesthesia
- Cardiovascular Research Institute, and
| | - Yaseen Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Gordon Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Lung Research, and
| | | | - Laurent J. Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Carolyn S. Calfee
- Department of Medicine
- Department of Anesthesia
- Cardiovascular Research Institute, and
| | - Alain Combes
- Médecine Intensive – Réanimation, Sorbonne Université, APHP Hôpital Pitié-Salpêtrière, Paris, France
| | - Brian M. Daniel
- Respiratory Therapy, University of California, San Francisco, San Francisco, California
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine and
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Gong
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Jeffrey E. Gotts
- Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | | | - John G. Laffey
- Anesthesia, University Hospital Galway, University of Galway, Galway, Ireland
| | | | - Flavia R. Machado
- Intensive Care Department, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Thomas R. Martin
- Department of Medicine, University of Washington, Seattle, Washington
| | - Danny F. McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Alain Mercat
- Medical ICU, Angers University Hospital, Angers, France
| | - Marc Moss
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | | | - Antonio Pesenti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Haibo Qiu
- Critical Care Medicine, Zhongda Hospital, Nanjing, China
| | | | - V. Marco Ranieri
- Emergency and Intensive Care Medicine, Alma Mater Studorium University of Bologna, Bologna, Italy
| | - Elisabeth D. Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Arthur S. Slutsky
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Theogene Twagirumugabe
- Department of Anesthesia, Critical Care, and Emergency Medicine, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda; and
| | - Lorraine B. Ware
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Katherine D. Wick
- Department of Medicine, University of California, Davis, Davis, California
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Agus A, McNamee JJ, Jackson C, McAuley DF. Extracorporeal carbon dioxide removal compared to ventilation alone in patients with acute hypoxaemic respiratory failure: cost-utility analysis of the REST RCT. Health Technol Assess 2023:1-26. [PMID: 37843629 PMCID: PMC10591206 DOI: 10.3310/fcdq8036] [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: 10/17/2023] Open
Abstract
Background Acute hypoxaemic respiratory failure requiring mechanical ventilation is a major cause of morbidity and mortality and has significant resource implications in terms of intensive care unit and hospital stay. Objective To assess the cost-effectiveness of extracorporeal carbon dioxide removal compared to ventilation alone in patients with acute hypoxaemic respiratory failure. Design A cost-utility analysis embedded within a pragmatic, multicentre, allocation-concealed, open-label, randomised controlled trial. Participants Four hundred and twelve (of a planned sample size of 1120) adult patients receiving mechanical ventilation for acute hypoxaemic respiratory failure, were recruited between May 2016 and December 2019 from 51 intensive care units in the UK. Interventions Participants were randomised (1 : 1) to receive extracorporeal carbon dioxide removal for at least 48 hours (n = 202) or standard care with ventilation alone (n = 210). Outcomes Health-related quality of life via the EuroQol-5 Dimensions, five-level version, health resource use and associated costs were measured over the study period. The cost per quality-adjusted life-year was estimated at 12 months post randomisation. Results Mean EuroQol-5 Dimensions, five-level version utility scores were low and similar for each group. Quality-adjusted life-years were calculated for those patients with complete EuroQol-5 Dimensions, five-level version data (extracorporeal carbon dioxide removal n = 140, ventilation alone n = 143) and there was no discernible difference in quality-adjusted life-years at 12 months (mean difference -0.01; 95% confidence interval -0.06 to 0.05; 140). Total 12-month health resource use cost (including intervention costs) was calculated for those patients with complete cost data (extracorporeal carbon dioxide removal n = 125, ventilation alone n = 126) and costs were statistically significantly higher in the extracorporeal carbon dioxide removal group (mean difference £7668.76, 95% confidence interval 159.75, 15,177.77). Multiple imputation was used for missing total cost and quality-adjusted life-year data in the cost-utility analysis. Ventilation alone dominated extracorporeal carbon dioxide removal and there was 0% probability of extracorporeal carbon dioxide removal being cost-effective compared to ventilation alone for all willingness to pay thresholds per quality-adjusted life-year considered (£0-50,000). Conclusions Extracorporeal carbon dioxide removal was associated with significantly higher costs, but no benefit in health-related quality of life. Given the data, extracorporeal carbon dioxide removal is not considered to be a cost-effective approach to treating patients with acute hypoxaemic respiratory failure. Limitations These included the absence of a baseline healthy utility score, minor data loss related to not obtaining complete intensive care unit readmission data for Scottish participants, and not estimating long-term cost-effectiveness due to the study closing early. Future work Measuring baseline health-related quality of life in critical care studies is difficult; future economic evaluations in this setting should consider measuring health-related quality of life as soon as possible after the patients regain capacity. Trial registration This trial is registered as NCT02654327 and ISRCTN 31262122. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 13/143/02.
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Affiliation(s)
- Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - James J McNamee
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | | | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
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5
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Musalia M, Laha S, Cazalilla-Chica J, Allan J, Roach L, Twamley J, Nanda S, Verlander M, Williams A, Kempe I, Patel II, Campbell-West F, Blackwood B, McAuley DF. A user evaluation of speech/phrase recognition software in critically ill patients: a DECIDE-AI feasibility study. Crit Care 2023; 27:277. [PMID: 37430313 DOI: 10.1186/s13054-023-04420-x] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/27/2023] [Indexed: 07/12/2023] Open
Abstract
OBJECTIVES Evaluating effectiveness of speech/phrase recognition software in critically ill patients with speech impairments. DESIGN Prospective study. SETTING Tertiary hospital critical care unit in the northwest of England. PARTICIPANTS 14 patients with tracheostomies, 3 female and 11 male. MAIN OUTCOME MEASURES Evaluation of dynamic time warping (DTW) and deep neural networks (DNN) methods in a speech/phrase recognition application. Using speech/phrase recognition app for voice impaired (SRAVI), patients attempted mouthing various supported phrases with recordings evaluated by both DNN and DTW processing methods. Then, a trio of potential recognition phrases was displayed on the screen, ranked from first to third in order of likelihood. RESULTS A total of 616 patient recordings were taken with 516 phrase identifiable recordings. The overall results revealed a total recognition accuracy across all three ranks of 86% using the DNN method. The rank 1 recognition accuracy of the DNN method was 75%. The DTW method had a total recognition accuracy of 74%, with a rank 1 accuracy of 48%. CONCLUSION This feasibility evaluation of a novel speech/phrase recognition app using SRAVI demonstrated a good correlation between spoken phrases and app recognition. This suggests that speech/phrase recognition technology could be a therapeutic option to bridge the gap in communication in critically ill patients. WHAT IS ALREADY KNOWN ABOUT THIS TOPIC Communication can be attempted using visual charts, eye gaze boards, alphabet boards, speech/phrase reading, gestures and speaking valves in critically ill patients with speech impairments. WHAT THIS STUDY ADDS Deep neural networks and dynamic time warping methods can be used to analyse lip movements and identify intended phrases. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE AND POLICY Our study shows that speech/phrase recognition software has a role to play in bridging the communication gap in speech impairment.
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Affiliation(s)
- M Musalia
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - S Laha
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.
- Faculty of Health and Care, University of Central Lancashire, Preston, UK.
| | - J Cazalilla-Chica
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - J Allan
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - L Roach
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - J Twamley
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - S Nanda
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - M Verlander
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - A Williams
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - I Kempe
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - I I Patel
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | | | - B Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - D F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
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6
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Bailey M, Linden D, Guo-Parke H, Earley O, Peto T, McAuley DF, Taggart C, Kidney J. Vascular risk factors for COVID-19 ARDS: endothelium, contact-kinin system. Front Med (Lausanne) 2023; 10:1208866. [PMID: 37448794 PMCID: PMC10336249 DOI: 10.3389/fmed.2023.1208866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/05/2023] [Indexed: 07/15/2023] Open
Abstract
SARS-CoV-2 binds to ACE2 receptors, expressed within the lungs. Risk factors for hospitalization include hypertension, diabetes, ischaemic heart disease and obesity-conditions linked by the presence of endothelial pathology. Viral infection in this setting causes increased conversion of circulating Factor XII to its active form (FXIIa). This is the first step in the contact-kinin pathway, leading to synchronous activation of the intrinsic coagulation cascade and the plasma Kallikrein-Kinin system, resulting in clotting and inflammatory lung disease. Temporal trends are evident from blood results of hospitalized patients. In the first week of symptoms the activated partial thromboplastin time (APTT) is prolonged. This can occur when clotting factors are consumed as part of the contact (intrinsic) pathway. Platelet counts initially fall, reflecting their consumption in coagulation. Lymphopenia occurs after approximately 1 week, reflecting the emergence of a lymphocytic pneumonitis [COVID-19 acute respiratory distress syndrome (ARDS)]. Intrinsic coagulation also induces the contact-kinin pathway of inflammation. A major product of this pathway, bradykinin causes oedema with ground glass opacities (GGO) on imaging in early COVID-19. Bradykinin also causes release of the pleiotrophic cytokine IL-6, which causes lymphocyte recruitment. Thromobosis and lymphocytic pneumonitis are hallmark features of COVID-19 ARDS. In this review we examine the literature with particular reference to the contact-kinin pathway. Measurements of platelets, lymphocytes and APTT should be undertaken in severe infections to stratify for risk of developing ARDS.
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Affiliation(s)
- Melanie Bailey
- Mater Infirmorum Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Dermot Linden
- Mater Infirmorum Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
- Wellcome - Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Hong Guo-Parke
- Wellcome - Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Olivia Earley
- Mater Infirmorum Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Tunde Peto
- Mater Infirmorum Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
- Wellcome - Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Danny F. McAuley
- Mater Infirmorum Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
- Wellcome - Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Clifford Taggart
- Wellcome - Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Joseph Kidney
- Mater Infirmorum Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
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McGuigan PJ, Giallongo E, Blackwood B, Doidge J, Harrison DA, Nichol AD, Rowan KM, Shankar-Hari M, Skrifvars MB, Thomas K, McAuley DF. Publisher Correction: The effect of blood pressure on mortality following out‑of‑hospital cardiac arrest: a retrospective cohort study of the United Kingdom Intensive Care National Audit and Research Centre database. Crit Care 2023; 27:169. [PMID: 37143141 PMCID: PMC10161573 DOI: 10.1186/s13054-023-04458-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Affiliation(s)
- Peter J McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK.
- Wellcome‑Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK.
| | - Elisa Giallongo
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Bronagh Blackwood
- Wellcome‑Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - James Doidge
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - David A Harrison
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Alistair D Nichol
- University College Dublin Clinical Research Centre, St Vincent's University Hospital, Dublin, Ireland
- The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute of Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Helsinki, Finland
| | - Karen Thomas
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Wellcome‑Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
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8
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McGuigan PJ, Edwards J, Blackwood B, Dark P, Doidge JC, Harrison DA, Kitchen G, Lawson I, Nichol AD, Rowan KM, Shankar-Hari M, McAuley DF, McGuigan PJ. The association between time of in hospital cardiac arrest and mortality; a retrospective analysis of two UK databases. Resuscitation 2023; 186:109750. [PMID: 36842674 DOI: 10.1016/j.resuscitation.2023.109750] [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: 12/22/2022] [Revised: 02/02/2023] [Accepted: 02/18/2023] [Indexed: 02/26/2023]
Abstract
AIMS The incidence of in hospital cardiac arrest (IHCA) varies throughout the day. This study aimed to report the variation in incidence of IHCA, presenting rhythm and outcome based on the hour in which IHCA occurred. METHODS We conducted a retrospective analysis of the National Cardiac Arrest Audit (NCAA) including patients who suffered an IHCA from 1st April 2011 to 31st December 2019. We then linked the NCAA and intensive care Case Mix Programme databases to explore the effect of time of IHCA on hospital survival in the subgroup of patients admitted to intensive care following IHCA. RESULTS We identified 115,690 eligible patients in the NCAA database. Pulseless electrical activity was the commonest presenting rhythm (54.8%). 66,885 patients died in the immediate post resuscitation period. Overall, hospital survival in the NCAA cohort was 21.3%. We identified 13,858 patients with linked ICU admissions in the Case Mix Programme database; 37.0% survived to hospital discharge. The incidence of IHCA peaked at 06.00. Rates of return of spontaneous circulation, survival to hospital discharge and good neurological outcome were lowest between 05.00 and 07.00. Among those admitted to ICU, no clear diurnal variation in hospital survival was seen in the unadjusted or adjusted analysis. This pattern was consistent across all presenting rhythms. CONCLUSIONS We observed higher rates of IHCA, and poorer outcomes at night. However, in those admitted to ICU, this variation was absent. This suggests patient factors and processes of care issues contribute to the variation in IHCA seen throughout the day.
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Affiliation(s)
- Peter J McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK; Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, UK.
| | - Julia Edwards
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - James C Doidge
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, UK
| | - David A Harrison
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, UK
| | - Gareth Kitchen
- Faculty of Biology, Medicine, and Health, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK; Manchester Foundation Trust, Manchester, UK
| | - Izabella Lawson
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, UK
| | - Alistair D Nichol
- University College Dublin Clinical Research Centre, St Vincent's University Hospital, Dublin, Ireland; The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute of Regeneration and Repair, University of Edinburgh, UK; Royal Infirmary of Edinburgh, NHS Lothian, UK
| | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK; Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, UK
| | - Peter J McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK; Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, UK.
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9
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McGuigan PJ, Giallongo E, Blackwood B, Doidge J, Harrison DA, Nichol AD, Rowan KM, Shankar-Hari M, Skrifvars MB, Thomas K, McAuley DF. The effect of blood pressure on mortality following out-of-hospital cardiac arrest: a retrospective cohort study of the United Kingdom Intensive Care National Audit and Research Centre database. Crit Care 2023; 27:4. [PMID: 36604745 PMCID: PMC9817239 DOI: 10.1186/s13054-022-04289-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hypotension following out-of-hospital cardiac arrest (OHCA) may cause secondary brain injury and increase mortality rates. Current guidelines recommend avoiding hypotension. However, the optimal blood pressure following OHCA is unknown. We hypothesised that exposure to hypotension and hypertension in the first 24 h in ICU would be associated with mortality following OHCA. METHODS We conducted a retrospective analysis of OHCA patients included in the Intensive Care National Audit and Research Centre Case Mix Programme from 1 January 2010 to 31 December 2019. Restricted cubic splines were created following adjustment for important prognostic variables. We report the adjusted odds ratio for associations between lowest and highest mean arterial pressure (MAP) and systolic blood pressure (SBP) in the first 24 h of ICU care and hospital mortality. RESULTS A total of 32,349 patients were included in the analysis. Hospital mortality was 56.2%. The median lowest and highest MAP and SBP were similar in survivors and non-survivors. Both hypotension and hypertension were associated with increased mortality. Patients who had a lowest recorded MAP in the range 60-63 mmHg had the lowest associated mortality. Patients who had a highest recorded MAP in the range 95-104 mmHg had the lowest associated mortality. The association between SBP and mortality followed a similar pattern to MAP. CONCLUSIONS We found an association between hypotension and hypertension in the first 24 h in ICU and mortality following OHCA. The inability to distinguish between the median blood pressure of survivors and non-survivors indicates the need for research into individualised blood pressure targets for survivors following OHCA.
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Affiliation(s)
- Peter J McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK.
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK.
| | - Elisa Giallongo
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - James Doidge
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - David A Harrison
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Alistair D Nichol
- University College Dublin Clinical Research Centre, St Vincent's University Hospital, Dublin, Ireland
- The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute of Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Helsinki, Finland
| | - Karen Thomas
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
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10
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Hays LMC, Black M, Prunty MP, Murthy S, van de Veerdonk FL, Annane D, Binnie A, Burrell A, Derde LPG, Gordon AC, Green C, Guillon A, Keat K, Lawler PR, Lye DC, Mayr FB, McArthur CJ, McAuley DF, McVerry BJ, Morpeth SC, Phua J, Pletz M, Reyes LF, Saxena M, Seppelt I, Shankar-Hari M, Sligl WI, Turner AM, Uyeki TM, Vazquez-Grande G, Webb SA, Ainscough K, P Haren A, Hills T, Nichol A. Could treatment with immunomodulatory agents targeting IL-1, IL-6, or JAK signalling improve outcomes in patients with severe influenza pneumonia? A systematic and narrative review. HRB Open Res 2022. [DOI: 10.12688/hrbopenres.13613.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Influenza is a global cause of morbidity and mortality and a significant risk for a future pandemic infection. Host hyperinflammation, similar to that seen in COVID-19, may occur in response to influenza virus pneumonia, with Janus kinase (JAK) signalling and proinflammatory cytokines Interleukin (IL)-1 and IL-6 involved. Immune modulation treatment of hospitalised and critically ill COVID-19 patients, including with IL-6 and JAK inhibitors, has been found to be beneficial. Significant interest exists in the use of immunomodulatory agents targeting these pathways in the treatment of severe influenza pneumonia. Methods: We conducted a review with both systematic and narrative methods to assess whether, in patients with severe influenza pneumonia, treatment with immunomodulatory agents targeting IL-1, IL-6 or JAK signalling, in comparison to no immune modulation, is beneficial and improves clinical outcomes. Results: Our systematic search screened 5409 records and found no randomised controlled trials of IL-1, IL-6 or JAK immunomodulatory agents in patients with severe influenza pneumonia. To support this systematic search, we provide a narrative review of the biological rationale, previous use of these agents, including in hospitalised patients with COVID-19, and an overview of their safety profiles. Conclusions: Although immune modulation has proven successful in treating hospitalised and critically ill patients with COVID-19 and a biological rationale exists for testing these agents in influenza, no agents targeting IL-1, IL-6 or JAK signalling have been assessed in randomised controlled trials of patients with severe influenza pneumonia. This highlights a significant evidence gap.
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11
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Rowland MJ, Veenith T, Scomparin C, Wilson MH, Hutchinson PJ, Kolias AG, Lall R, Regan S, Mason J, Andrews PJD, Horner D, Naisbitt J, Devrell A, Malins A, Dark P, McAuley DF, Perkins GD. Sugar or salt ("SOS"): A protocol for a UK multicentre randomised trial of mannitol and hypertonic saline in severe traumatic brain injury and intracranial hypertension. J Intensive Care Soc 2022; 23:222-232. [PMID: 35615234 PMCID: PMC9125440 DOI: 10.1177/1751143720901690] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
Hyperosmolar solutions are widely used to treat raised intracranial pressure following severe traumatic brain injury. Although mannitol has historically been the most frequently administered, hypertonic saline solutions are increasingly being used. However, definitive evidence regarding their comparative effectiveness is lacking. The Sugar or Salt Trial is a UK randomised, allocation concealed open label multicentre pragmatic trial designed to determine the clinical and cost-effectiveness of hypertonic saline compared with mannitol in the management of patients with severe traumatic brain injury. Patients requiring intensive care unit admission and intracranial pressure monitoring post-traumatic brain injury will be allocated at random to receive equi-osmolar boluses of either mannitol or hypertonic saline following failure of routine first-line measures to control intracranial pressure. The primary outcome for the study will be the Extended Glasgow Outcome Scale assessed at six months after randomisation. Results will inform current clinical practice in the routine use of hyperosmolar therapy as well as assess the impact of potential side effects. Pre-planned longer term clinical and cost effectiveness analyses will further inform the use of these treatments.
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Affiliation(s)
- MJ Rowland
- Kadoorie Centre for Critical Care Research,
Nuffield Division of Anaesthesia, University of Oxford, Oxford, UK
- Adult Intensive Care Unit,
Oxford
University Hospitals NHS Foundation Trust, Oxford,
UK
| | - T Veenith
- Institute of Inflammation and Ageing,
University
of Birmingham, Birmingham, UK
- Critical Care Directorate,
University
Hospitals Birmingham NHS Foundation Trust,
Birmingham, UK
| | - C Scomparin
- Warwick Clinical Trials Unit,
University
of Warwick, Coventry, UK
| | - MH Wilson
- Imperial Neurotrauma Centre, Department of
Neurosurgery, St Mary’s Hospital, London, UK
| | - PJ Hutchinson
- Division of Neurosurgery, Department of
Clinical Neurosciences,
University
of Cambridge, Cambridge, UK
| | - AG Kolias
- Division of Neurosurgery, Department of
Clinical Neurosciences,
University
of Cambridge, Cambridge, UK
| | - R Lall
- Warwick Clinical Trials Unit,
University
of Warwick, Coventry, UK
| | - S Regan
- Warwick Clinical Trials Unit,
University
of Warwick, Coventry, UK
| | - J Mason
- Warwick Clinical Trials Unit,
University
of Warwick, Coventry, UK
| | - PJD Andrews
- Centre for Clinical Brain Sciences, University
of Edinburgh, Edinburgh, UK
| | - D Horner
- Department of Critical Care,
Salford
Royal NHS Foundation Trust, UK
| | - J Naisbitt
- Department of Critical Care,
Salford
Royal NHS Foundation Trust, UK
| | - A Devrell
- Warwick Clinical Trials Unit,
University
of Warwick, Coventry, UK
| | - A Malins
- Warwick Clinical Trials Unit,
University
of Warwick, Coventry, UK
| | - P Dark
- Department of Critical Care,
Salford
Royal NHS Foundation Trust, UK
- Manchester NIHR Biomedical Research Centre,
University of Manchester, Manchester, UK
| | - DF McAuley
- Regional Intensive Care Unit,
Royal
Victoria Hospital, Belfast Health and Social Care
Trust, Belfast, UK
- The Wellcome Wolfson Institute for
Experimental Medicine, Queens University Belfast, Belfast, UK
| | - GD Perkins
- Critical Care Directorate,
University
Hospitals Birmingham NHS Foundation Trust,
Birmingham, UK
- Warwick Clinical Trials Unit,
University
of Warwick, Coventry, UK
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12
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Johnston BW, Chean CS, Duarte R, Hill R, Blackwood B, McAuley DF, Welters ID. Management of new onset atrial fibrillation in critically unwell adult patients: a systematic review and narrative synthesis. Br J Anaesth 2021; 128:759-771. [PMID: 34916053 DOI: 10.1016/j.bja.2021.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND New onset atrial fibrillation (NOAF) is the most common arrhythmia affecting critically unwell patients. NOAF can lead to worsening haemodynamic compromise, heart failure, thromboembolic events, and increased mortality. The aim of this systematic review and narrative synthesis is to evaluate the non-pharmacological and pharmacological management strategies for NOAF in critically unwell patients. METHODS Of 1782 studies, 30 were eligible for inclusion, including 4 RCTs and 26 observational studies. Efficacy of direct current cardioversion, amiodarone, β-antagonists, calcium channel blockers, digoxin, magnesium, and less commonly used agents such as ibutilide are reported. RESULTS Cardioversion rates of 48% were reported for direct current cardioversion; however, re-initiation of NOAF was as high as 23.4%. Amiodarone was the most commonly reported intervention with cardioversion rates ranging from 18% to 95.8% followed by β-antagonists with cardioversion rates from 40% to 92.3%. Amiodarone was more effective than diltiazem (odds ratio [OR]=1.91, P=0.32) at cardioversion. Short-acting β-antagonists esmolol and landiolol were more effective compared with diltiazem at cardioversion (OR=3.55, P=0.04) and HR control (OR=3.2, P<0.001). CONCLUSION There was significant variation between studies with regard to the definition of successful cardioversion and heart rate control, making comparisons between studies and interventions difficult. Future RCTs comparing individual anti-arrhythmic agents, in particular magnesium, amiodarone, and β-antagonists, and the role of anticoagulation in critically unwell patients are required. There is also an urgent need for a core outcome dataset for studies of new onset atrial fibrillation to allow comparisons between different anti-arrhythmic strategies. CLINICAL TRIAL REGISTRATION PROSPERO CRD42019121739.
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Affiliation(s)
- Brian W Johnston
- Institute for Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
| | - Chung S Chean
- Northampton General Hospital NHS Trust, Northampton, UK
| | - Rui Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Danny F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Ingeborg D Welters
- Institute for Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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13
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Reddy K, Calfee CS, McAuley DF. Acute Respiratory Distress Syndrome Subphenotypes beyond the Syndrome: A Step toward Treatable Traits? Am J Respir Crit Care Med 2021; 203:1449-1451. [PMID: 33565943 PMCID: PMC8483225 DOI: 10.1164/rccm.202101-0218ed] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kiran Reddy
- Department of Anaesthesiology, Intensive Care, and Pain Medicine Mater Misericordiae University Hospital Dublin, Ireland, and.,University College Dublin Dublin, Ireland
| | - Carolyn S Calfee
- Department of Medicine, and.,Department of Anesthesia University of California San Francisco, California
| | - Danny F McAuley
- Department of Medicine, Dentistry and Biomedical Sciences Queen's University Belfast Belfast, United Kingdom, and.,Regional Intensive Care Unit Royal Victoria Hospital Belfast, United Kingdom
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14
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Newcombe V, Coats T, Dark P, Gordon A, Harris S, McAuley DF, Menon DK, Price S, Puthucheary Z, Singer M. The future of acute and emergency care. Future Healthc J 2021; 8:e230-e236. [PMID: 34286190 DOI: 10.7861/fhj.2021-0097] [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: 11/27/2022]
Abstract
Improved outcomes for acutely unwell patients are predicated on early identification of deterioration, accelerating the time to accurate diagnosis of the underlying condition, selection and titration of treatments that target biological phenotypes, and personalised endpoints to achieve optimal benefit yet minimise iatrogenic harm. Technological developments entering routine clinical practice over the next decade will deliver a sea change in patient management. Enhanced point of care diagnostics, more sophisticated physiological and biochemical monitoring with superior analytics and computer-aided support tools will all add considerable artificial intelligence to complement clinical skills. Experts in different fields of emergency and critical care medicine offer their perspectives as to which research developments could make a big difference within the next decade.
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Affiliation(s)
| | | | - Paul Dark
- Manchester NIHR Biomedical Research Centre, Manchester, UK and Northern Care Alliance NHS Group, Manchester, UK
| | | | - Steve Harris
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Danny F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Belfast, UK and Royal Victoria Hospital, Belfast, UK
| | | | - Susanna Price
- Royal Brompton Hospital, London, UK and National Heart and Lung Institute, London, UK
| | - Zudin Puthucheary
- William Harvey Research Institute, London, UK and Royal London Hospital, London, UK
| | - Mervyn Singer
- University College London Hospitals NHS Foundation Trust, London, UK and Bloomsbury Institute for Intensive Care Medicine, London, UK
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15
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Dutra Silva J, Su Y, Calfee CS, Delucchi KL, Weiss D, McAuley DF, O'Kane C, Krasnodembskaya AD. Mesenchymal stromal cell extracellular vesicles rescue mitochondrial dysfunction and improve barrier integrity in clinically relevant models of ARDS. Eur Respir J 2021; 58:13993003.02978-2020. [PMID: 33334945 PMCID: PMC8318599 DOI: 10.1183/13993003.02978-2020] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/02/2020] [Indexed: 12/22/2022]
Abstract
Alveolar epithelial–capillary barrier disruption is a hallmark of acute respiratory distress syndrome (ARDS). Contribution of mitochondrial dysfunction to the compromised alveolar-capillary barrier in ARDS remains unclear. Mesenchymal stromal cells-derived extracellular vesicles (MSC-EVs) are considered as a cell-free therapy for ARDS. Mitochondrial transfer was shown to be important for the therapeutic effects of MSCs and MSC-EVs. Here we investigated the contribution of mitochondrial dysfunction to the injury of alveolar epithelial and endothelial barriers in ARDS and the ability of MSC-EVs to modulate alveolar–capillary barrier integrity through mitochondrial transfer. Primary human small airway epithelial and pulmonary microvascular endothelial cells and human precision cut lung slices (PCLSs) were stimulated with endotoxin or plasma samples from patients with ARDS and treated with MSC-EVs, barrier properties and mitochondrial functions were evaluated. Lipopolysaccharide (LPS)-injured mice were treated with MSC-EVs and degree of lung injury and mitochondrial respiration of the lung tissue were assessed. Inflammatory stimulation resulted in increased permeability coupled with pronounced mitochondrial dysfunction in both types of primary cells and PCLSs. Extracellular vesicles derived from normal MSCs restored barrier integrity and normal levels of oxidative phosphorylation while an extracellular vesicles preparation which did not contain mitochondria was not effective. In vivo, presence of mitochondria was critical for extracellular vesicles ability to reduce lung injury and restore mitochondrial respiration in the lung tissue. In the ARDS environment, MSC-EVs improve alveolar–capillary barrier properties through restoration of mitochondrial functions at least partially via mitochondrial transfer. This study demonstrates that mitochondrial dysfunction is an important mechanism of ARDS pathogenesis. Mitochondrial transfer is crucial for the ability of MSC extracellular vesicles to restore integrity of the alveolar–capillary barrier.https://bit.ly/2JuqoCY
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Affiliation(s)
- Johnatas Dutra Silva
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Yue Su
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Carolyn S Calfee
- Dept of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA.,Dept of Anesthesia, University of California, San Francisco, San Francisco, CA, USA.,Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Kevin L Delucchi
- Dept of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Weiss
- Dept of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Danny F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Cecilia O'Kane
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Anna D Krasnodembskaya
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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16
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Loughlin L, McAuley DF, Simpson AJ, McMullan R. Reply to Aberegg and Wolfe: Aspergillosis in the ICU: Hidden Enemy or Bogeyman? Am J Respir Crit Care Med 2021; 203:1044-1045. [PMID: 33497595 PMCID: PMC8048741 DOI: 10.1164/rccm.202101-0026le] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | - A John Simpson
- Newcastle University Newcastle upon Tyne, United Kingdom
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17
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George PM, Barratt SL, Condliffe R, Desai SR, Devaraj A, Forrest I, Gibbons MA, Hart N, Jenkins RG, McAuley DF, Patel BV, Thwaite E, Spencer LG. Respiratory follow-up of patients with COVID-19 pneumonia. Thorax 2020; 75:1009-1016. [PMID: 32839287 PMCID: PMC7447111 DOI: 10.1136/thoraxjnl-2020-215314] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [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: 05/18/2020] [Revised: 06/16/2020] [Accepted: 07/03/2020] [Indexed: 01/08/2023]
Abstract
The COVID-19 pandemic has led to an unprecedented surge in hospitalised patients with viral pneumonia. The most severely affected patients are older men, individuals of black and Asian minority ethnicity and those with comorbidities. COVID-19 is also associated with an increased risk of hypercoagulability and venous thromboembolism. The overwhelming majority of patients admitted to hospital have respiratory failure and while most are managed on general wards, a sizeable proportion require intensive care support. The long-term complications of COVID-19 pneumonia are starting to emerge but data from previous coronavirus outbreaks such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) suggest that some patients will experience long-term respiratory complications of the infection. With the pattern of thoracic imaging abnormalities and growing clinical experience, it is envisaged that interstitial lung disease and pulmonary vascular disease are likely to be the most important respiratory complications. There is a need for a unified pathway for the respiratory follow-up of patients with COVID-19 balancing the delivery of high-quality clinical care with stretched National Health Service (NHS) resources. In this guidance document, we provide a suggested structure for the respiratory follow-up of patients with clinicoradiological confirmation of COVID-19 pneumonia. We define two separate algorithms integrating disease severity, likelihood of long-term respiratory complications and functional capacity on discharge. To mitigate NHS pressures, virtual solutions have been embedded within the pathway as has safety netting of patients whose clinical trajectory deviates from the pathway. For all patients, we suggest a holistic package of care to address breathlessness, anxiety, oxygen requirement, palliative care and rehabilitation.
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Affiliation(s)
- Peter M George
- Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Shaney L Barratt
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
- University of Bristol School of Clinical Science, Bristol, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Sujal R Desai
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anand Devaraj
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ian Forrest
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Michael A Gibbons
- Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Nicholas Hart
- Lane Fox Respiratory Service, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - R Gisli Jenkins
- Centre for Respiratory Research, University of Nottingham, Nottingham, UK
| | - Danny F McAuley
- Intensive Care Unit, Queen's University Belfast, Belfast, UK
| | - Brijesh V Patel
- Department of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, London, UK
| | - Erica Thwaite
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Lisa G Spencer
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
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18
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Loughlin L, Hellyer TP, White PL, McAuley DF, Conway Morris A, Posso RB, Richardson MD, Denning DW, Simpson AJ, McMullan R. Pulmonary Aspergillosis in Patients with Suspected Ventilator-associated Pneumonia in UK ICUs. Am J Respir Crit Care Med 2020; 202:1125-1132. [PMID: 32609533 PMCID: PMC7560800 DOI: 10.1164/rccm.202002-0355oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [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
Rationale:Aspergillus infection in patients with suspected ventilator-associated pneumonia remains uncharacterized because of the absence of a disease definition and limited access to sensitive diagnostic tests.Objectives: To estimate the prevalence and outcomes of Aspergillus infection in adults with suspected ventilator-associated pneumonia.Methods: Two prospective UK studies recruited 360 critically ill adults with new or worsening alveolar shadowing on chest X-ray and clinical/hematological parameters supporting suspected ventilator-associated pneumonia. Stored serum and BAL fluid were available from 194 nonneutropenic patients and underwent mycological testing. Patients were categorized as having probable Aspergillus infection using a definition comprising clinical, radiological, and mycological criteria. Mycological criteria included positive histology or microscopy, positive BAL fluid culture, galactomannan optical index of 1 or more in BAL fluid or 0.5 or more in serum.Measurements and Main Results: Of 194 patients evaluated, 24 met the definition of probable Aspergillus infection, giving an estimated prevalence of 12.4% (95% confidence interval, 8.1-17.8). All 24 patients had positive galactomannan in serum (n = 4), BAL fluid (n = 16), or both (n = 4); three patients cultured Aspergillus sp. in BAL fluid. Patients with probable Aspergillus infection had a significantly longer median duration of critical care stay (25.5 vs. 15.5 d, P = 0.02). ICU mortality was numerically higher in this group, although this was not statistically significant (33.3% vs. 22.8%; P = 0.23).Conclusions: The estimated prevalence for probable Aspergillus infection in this geographically dispersed multicenter UK cohort indicates that this condition should be considered when investigating patients with suspected ventilator-associated pneumonia, including patient groups not previously recognized to be at high risk of aspergillosis.
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Affiliation(s)
- Laura Loughlin
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - P Lewis White
- Public Health Wales, Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Danny F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom; and
| | - Raquel B Posso
- Public Health Wales, Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Malcolm D Richardson
- UK NHS Mycology Reference Centre, Manchester University NHS Foundation Trust and
| | - David W Denning
- The University of Manchester and Manchester Academic Health Science Centre, National Aspergillosis Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
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19
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McGuigan PJ, Shankar-Hari M, Harrison DA, Laffey JG, McAuley DF. The interaction between arterial oxygenation and carbon dioxide and hospital mortality following out of hospital cardiac arrest: a cohort study. Crit Care 2020; 24:336. [PMID: 32532312 PMCID: PMC7290139 DOI: 10.1186/s13054-020-03039-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 05/27/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Outcomes following out of hospital cardiac arrest (OHCA) are poor. The optimal arterial oxygen and carbon dioxide (PaCO2) levels for managing patients following OHCA are unknown. We hypothesized that abnormalities in arterial oxygenation (PaO2/FiO2 ratio or PaO2) and PaCO2 would be associated with hospital mortality following OHCA. We hypothesized that PaCO2 would significantly modify the oxygenation-mortality relationship. METHODS This was an observational cohort study using data from OHCA survivors admitted to adult critical care units in England, Wales and Northern Ireland from 2011 to 2018. Logistic regression analyses were performed to assess the relationship between hospital mortality and oxygenation and PaCO2. RESULTS The analysis included 23,625 patients. In comparison with patients with a PaO2/FiO2 > 300 mmHg, those with a PaO2/FiO2 ≤ 100 mmHg had higher mortality (adjusted OR, 1.79; 95% CI, 1.48 to 2.15; P < 0.001). In comparison to hyperoxemia (PaO2 > 100 mmHg), patients with hypoxemia (PaO2 < 60 mmHg) had higher mortality (adjusted OR, 1.34; 95% CI, 1.10 to 1.65; P = 0.004). In comparison with normocapnia, hypercapnia was associated with lower mortality. Hypocapnia (PaCO2 ≤ 35 mmHg) was associated with higher mortality (adjusted OR, 1.91; 95% CI, 1.63 to 2.24; P < 0.001). PaCO2 modified the PaO2/FiO2-mortality and PaO2-mortality relationships, though these relationships were complex. Patients who were both hyperoxic and hypercapnic had the lowest mortality. CONCLUSIONS Low PaO2/FiO2 ratio, hypoxemia and hypocapnia are associated with higher mortality following OHCA. PaCO2 modifies the relationship between oxygenation and mortality following OHCA; future studies examining this interaction are required.
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Affiliation(s)
- Peter J McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, BT12 6BA, UK.
| | - Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, St Thomas' Hospital, 1st Floor, East Wing, London, SE1 7EH, UK.,School of Immunology & Microbial Sciences, Kings College London, London, SE1 9RT, UK.,Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - David A Harrison
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, Regenerative Medicine Institute (REMEDI), CÚRAM Centre for Research in Medical Devices National University of Ireland Galway, Galway, Ireland.,Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, BT12 6BA, UK.,Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, BT9 7AE, UK
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20
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Forde C, McMullan R, Clarke M, Wilson RH, Plummer R, Grayson M, McDowell C, Agus A, Doran A, McAuley DF, Thomas AL, Barnes RA, Adams R, Chau I, Coyle V. Early switch from intravenous to oral antibiotic therapy in patients with cancer who have low-risk neutropenic sepsis (the EASI-SWITCH trial): study protocol for a randomised controlled trial. Trials 2020; 21:431. [PMID: 32460818 PMCID: PMC7251886 DOI: 10.1186/s13063-020-04241-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/10/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Neutropenic sepsis remains a common treatment complication for patients receiving systemic anti-cancer treatment. The UK National Institute for Health and Care Excellence have not recommended switching from empirical intravenous antibiotics to oral antibiotics within 48 h for patients assessed as low risk for septic complications because of uncertainty about whether this would achieve comparable outcomes to using intravenous antibiotics for longer. The UK National Institute for Health Research funded the EASI-SWITCH trial to tackle this uncertainty. METHODS The trial is a pragmatic, randomised, non-inferiority trial that aims to establish the clinical and cost-effectiveness of early switching from intravenous to oral antibiotics in cancer patients with low-risk neutropenic sepsis. Patients ≥ 16 years, receiving systemic anti-cancer treatment (acute leukaemics/stem cell transplants excluded), with a temperature of > 38 °C, neutrophil count ≤ 1.0 × 109/L, MASCC (Multinational Association of Supportive Care in Cancer) score ≥ 21 and receiving IV piperacillin/tazobactam or meropenem for less than 24 h are eligible to participate. Patients are randomised 1:1 either (i) to switch to oral ciprofloxacin and co-amoxiclav within 12-24 h of commencing intravenous antibiotics, completing at least 5 days total antibiotics (intervention), or (ii) to continue intravenous antibiotics for at least 48 h, with ongoing antibiotics being continued at the physician's discretion (control). Patients are discharged home when their physician deems it appropriate. The primary outcome measure is a composite of treatment failures as assessed at day 14. The criteria for treatment failure include fever persistence or recurrence 72 h after starting intravenous antibiotics, escalation from protocolised antibiotics, hospital readmission related to infection/antibiotics, critical care support or death. Based on a 15% treatment failure rate in the control group and a 15% non-inferiority margin, the recruitment target is 230 patients. DISCUSSION If the trial demonstrates non-inferiority of early switching to oral antibiotics, with potential benefits for patient quality of life and resource savings, this finding will have significant implications for the routine clinical management of those with low-risk neutropenic sepsis. TRIAL REGISTRATION ISRCTN: 84288963. Registered on the 1 July 2015. https://doi.org/10.1186/ISRCTN84288963. EudraCT: 2015-002830-35.
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Affiliation(s)
- Caroline Forde
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Lisburn Road, Belfast, BT9 7AE UK
| | - Ronan McMullan
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, UK
| | - Mike Clarke
- Northern Ireland Methodology Hub, Queen’s University Belfast, Belfast, UK
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | | | - Ruth Plummer
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK
| | | | - Cliona McDowell
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Annmarie Doran
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Danny F. McAuley
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | | | | | - Richard Adams
- Cardiff University and Velindre NHS Trust, Cardiff, UK
| | - Ian Chau
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Vicky Coyle
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Lisburn Road, Belfast, BT9 7AE UK
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21
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Abrams D, Schmidt M, Pham T, Beitler JR, Fan E, Goligher EC, McNamee JJ, Patroniti N, Wilcox ME, Combes A, Ferguson ND, McAuley DF, Pesenti A, Quintel M, Fraser J, Hodgson CL, Hough CL, Mercat A, Mueller T, Pellegrino V, Ranieri VM, Rowan K, Shekar K, Brochard L, Brodie D. Mechanical Ventilation for Acute Respiratory Distress Syndrome during Extracorporeal Life Support. Research and Practice. Am J Respir Crit Care Med 2020; 201:514-525. [DOI: 10.1164/rccm.201907-1283ci] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Darryl Abrams
- Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, New York
- Center for Acute Respiratory Failure, Columbia University Medical Center, New York, New York
| | - Matthieu Schmidt
- INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Tài Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France
| | - Jeremy R. Beitler
- Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, New York
- Center for Acute Respiratory Failure, Columbia University Medical Center, New York, New York
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - James J. McNamee
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Nicolò Patroniti
- Anaesthesia and Intensive Care, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) for Oncology, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - M. Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Alain Combes
- INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Danny F. McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Michael Quintel
- Department of Anesthesiology, University Medical Center, Georg August University, Goettingen, Germany
| | - John Fraser
- Critical Care Research Group, Prince Charles Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Carol L. Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Physiotherapy Department and
| | - Catherine L. Hough
- Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Alain Mercat
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire d’Angers, Université d’Angers, Angers, France
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital of Regensburg, Regensburg, Germany
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
| | - V. Marco Ranieri
- Alma Mater Studiorum–Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant’Orsola, Università di Bologna, Bologna, Italy; and
| | - Kathy Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Kiran Shekar
- Critical Care Research Group, Prince Charles Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Daniel Brodie
- Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, New York
- Center for Acute Respiratory Failure, Columbia University Medical Center, New York, New York
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22
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von Bahr V, Millar JE, Malfertheiner MV, Ki KK, Passmore MR, Bartnikowski N, Redd MA, Cavaye M, Suen JY, McAuley DF, Fraser JF. Mesenchymal stem cells may ameliorate inflammation in an ex vivo model of extracorporeal membrane oxygenation. Perfusion 2020; 34:15-21. [PMID: 30966907 DOI: 10.1177/0267659119830857] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Mesenchymal stem cells exhibit immunomodulatory properties which are currently being investigated as a novel treatment option for Acute Respiratory Distress Syndrome. However, the feasibility and efficacy of mesenchymal stem cell therapy in the setting of extracorporeal membrane oxygenation is poorly understood. This study aimed to characterise markers of innate immune activation in response to mesenchymal stem cells during an ex vivo simulation of extracorporeal membrane oxygenation. METHODS Ex vivo extracorporeal membrane oxygenation simulations (n = 10) were conducted using a commercial extracorporeal circuit with a CO2-enhanced fresh gas supply and donor human whole blood. Heparinised circuits (n = 4) were injected with 40 × 106-induced pluripotent stem cell-derived human mesenchymal stem cells, while the remainder (n = 6) acted as controls. Simulations were maintained, under physiological conditions, for 240 minutes. Circuits were sampled at 15, 30, 60, 120 and 240 minutes and assessed for levels of interleukin-1β, interleukin-6, interleukin-8, interleukin-10, tumour necrosis factor-α, transforming growth factor-β1, myeloperoxidase and α-Defensin-1. In addition, haemoglobin, platelet and leukocyte counts were performed. RESULTS There was a trend towards reduced levels of pro-inflammatory cytokines in mesenchymal stem cell-treated circuits and a significant increase in transforming growth factor-β1. Blood cells and markers of neutrophil activation were reduced in mesenchymal stem cell circuits during the length of the simulation. As previously reported, the addition of mesenchymal stem cells resulted in a reduction of flow and increased trans-oxygenator pressures in comparison to controls. CONCLUSIONS The addition of mesenchymal stem cells during extracorporeal membrane oxygenation may cause an increase in transforming growth factor-β1. This is despite their ability to adhere to the membrane oxygenator. Further studies are required to confirm these findings.
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Affiliation(s)
- Viktor von Bahr
- 1 Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD, Australia
- 2 Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jonathan E Millar
- 1 Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD, Australia
- 3 Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Maximillian V Malfertheiner
- 1 Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD, Australia
- 4 Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Katrina K Ki
- 1 Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD, Australia
| | - Margaret R Passmore
- 1 Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD, Australia
| | - Nicole Bartnikowski
- 1 Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD, Australia
| | - Meredith A Redd
- 5 Institute for Molecular Bioscience, University of Queensland, Brisbane, QLD, Australia
| | - Michael Cavaye
- 1 Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD, Australia
| | - Jacky Y Suen
- 1 Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD, Australia
| | - Danny F McAuley
- 3 Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - John F Fraser
- 1 Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD, Australia
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23
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Affiliation(s)
- Rohan Anand
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - John Norrie
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Judy M Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Danny F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Mike Clarke
- Northern Ireland Clinical Trials Unit and Methodology Hub, Centre for Public Health, Queen's University Belfast, Belfast, UK
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24
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Bradley JM, Anand R, O’Neill B, Ferguson K, Clarke M, Carroll M, Chalmers J, De Soyza A, Duckers J, Hill AT, Loebinger MR, Copeland F, Gardner E, Campbell C, Agus A, McGuire A, Boyle R, McKinney F, Dickson N, McAuley DF, Elborn S. A 2 × 2 factorial, randomised, open-label trial to determine the clinical and cost-effectiveness of hypertonic saline (HTS 6%) and carbocisteine for airway clearance versus usual care over 52 weeks in adults with bronchiectasis: a protocol for the CLEAR clinical trial. Trials 2019; 20:747. [PMID: 31856887 PMCID: PMC6921594 DOI: 10.1186/s13063-019-3766-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 09/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current guidelines for the management of bronchiectasis (BE) highlight the lack of evidence to recommend mucoactive agents, such as hypertonic saline (HTS) and carbocisteine, to aid sputum removal as part of standard care. We hypothesise that mucoactive agents (HTS or carbocisteine, or a combination) are effective in reducing exacerbations over a 52-week period, compared to usual care. METHODS This is a 52-week, 2 × 2 factorial, randomized, open-label trial to determine the clinical effectiveness and cost effectiveness of HTS 6% and carbocisteine for airway clearance versus usual care - the Clinical and cost-effectiveness of hypertonic saline (HTS 6%) and carbocisteine for airway clearance versus usual care (CLEAR) trial. Patients will be randomised to (1) standard care and twice-daily nebulised HTS (6%), (2) standard care and carbocisteine (750 mg three times per day until visit 3, reducing to 750 mg twice per day), (3) standard care and combination of twice-daily nebulised HTS and carbocisteine, or (4) standard care. The primary outcome is the mean number of exacerbations over 52 weeks. Key inclusion criteria are as follows: adults with a diagnosis of BE on computed tomography, BE as the primary respiratory diagnosis, and two or more pulmonary exacerbations in the last year requiring antibiotics and production of daily sputum. DISCUSSION This trial's pragmatic research design avoids the significant costs associated with double-blind trials whilst optimising rigour in other areas of trial delivery. The CLEAR trial will provide evidence as to whether HTS, carbocisteine or both are effective and cost effective for patients with BE. TRIAL REGISTRATION EudraCT number: 2017-000664-14 (first entered in the database on 20 October 2017). ISRCTN.com, ISRCTN89040295. Registered on 6 July/2018. Funder: National Institute for Health Research, Health Technology Assessment Programme (15/100/01). SPONSOR Belfast Health and Social Care Trust. Ethics Reference Number: 17/NE/0339. Protocol version: v3.0 Final_14052018.
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Affiliation(s)
- Judy Martina Bradley
- Wellcome-Wolfson Institute For Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Rohan Anand
- Wellcome-Wolfson Institute For Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Brenda O’Neill
- Centre for Health and Rehabilitation Technologies (CHaRT), Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Kathryn Ferguson
- Northern Ireland Clinical Research Network, Belfast Health and Social Care Trust, Belfast, UK
| | - Mike Clarke
- Northern Ireland Methodology Hub, Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Mary Carroll
- Southampton University Hospitals NHS Trust, Southampton, UK
| | | | - Anthony De Soyza
- NIHR Biomedical research centre (BRC) for Aging, Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Jamie Duckers
- Cardiff and Vale University Health Board, University Hospital Llandough, Penarth, UK
| | - Adam T. Hill
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Michael R. Loebinger
- Faculty of Medicine, National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London, UK
| | - Fiona Copeland
- PCD Family Support Group, Ciliopathy Alliance, London, UK
| | - Evie Gardner
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Christina Campbell
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Alistair McGuire
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Roisin Boyle
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Fionnuala McKinney
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Naomi Dickson
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Danny F. McAuley
- Wellcome-Wolfson Institute For Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Stuart Elborn
- Wellcome-Wolfson Institute For Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
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25
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Johnston BW, Hill R, Duarte R, Chean CS, McAuley DF, Blackwood B, Pace N, Welters ID. Protocol for a systematic review and network meta-analysis of the management of new onset atrial fibrillation in critically unwell adult patients. Syst Rev 2019; 8:242. [PMID: 31661022 PMCID: PMC6816145 DOI: 10.1186/s13643-019-1149-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND New onset atrial fibrillation is the most commonly encountered arrhythmia in critically unwell patients with a reported incidence of 4% to 29%. The occurrence of new onset atrial fibrillation may precipitate acute heart failure and lead to thromboembolic complications as well as being associated with increased in-hospital and in intensive care unit (ICU) mortality. Despite being common, much of our current knowledge regarding the treatment of new onset atrial fibrillation comes from patients with chronic atrial fibrillation or post cardiac surgery. It is unclear if management strategies in these patient cohorts can be applied to new onset atrial fibrillation in the general ICU. This protocol for a systematic review and network meta-analysis aims to address this uncertainty and define what is the most effective management strategy for the treatment of new onset atrial fibrillation (NOAF) in acutely unwell adult patients. METHODS In this systematic review and network meta-analysis, we plan to search electronic databases (Cochrane Central Register of Controlled Trials [CENTRAL], MEDLINE, EMBASE, Science Citation Index Expanded on Web of Science and relevant trial registries) for relevant randomised and non-randomised trials. Citations will be reviewed by title, abstract and full text by two independent reviewers and disagreement resolved by discussion and a third independent reviewer, if necessary. The Cochrane Risk of Bias tool will be used to assess risk of bias in randomised trials and the Risk of Bias in Nonrandomised Studies of Interventions (ROBINS-I) tool will be used for non-randomised studies. Statistical analysis will be carried out using R package meta and netmeta. We will first conduct a pairwise meta-analysis. If conditions for indirect comparison are satisfied and suitable data are available, we will conduct network meta-analysis using frequentist methodology. Treatments will be ranked according to efficacy with associated P-scores. We will assess the quality of the evidence in the pairwise using GRADE methodology and network meta-analysis comparisons in the CINeMA module in R package meta. DISCUSSION Our review will be the first to assess direct and indirect evidence to assess the efficacy and rank the treatments available for new onset atrial fibrillation in critically unwell patients. Our review findings will be applicable to the care of people in a range of acute settings including, ICU, the emergency department and acute medical units. SYSTEMATIC REVIEW REGISTRATION PROSPERO registry number: CRD42019121739.
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Affiliation(s)
- Brian W. Johnston
- University of Liverpool and The Royal Liverpool and Broadgreen University Hospitals, Liverpool Health Partners, Liverpool, UK
| | - Ruaraidh Hill
- University of Liverpool and The Royal Liverpool and Broadgreen University Hospitals, Liverpool Health Partners, Liverpool, UK
| | - Rui Duarte
- University of Liverpool and The Royal Liverpool and Broadgreen University Hospitals, Liverpool Health Partners, Liverpool, UK
| | - Chung Shen Chean
- University of Liverpool and The Royal Liverpool and Broadgreen University Hospitals, Liverpool Health Partners, Liverpool, UK
| | - Danny F. McAuley
- Wellcome-Wolfson Institute of Experimental Medicine, Queen’s University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute of Experimental Medicine, Queen’s University Belfast, Belfast, UK
| | | | - Ingeborg D. Welters
- University of Liverpool and The Royal Liverpool and Broadgreen University Hospitals, Liverpool Health Partners, Liverpool, UK
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26
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Linden D, Guo-Parke H, Coyle PV, Fairley D, McAuley DF, Taggart CC, Kidney J. Respiratory viral infection: a potential "missing link" in the pathogenesis of COPD. Eur Respir Rev 2019; 28:28/151/180063. [PMID: 30872396 DOI: 10.1183/16000617.0063-2018] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 11/19/2018] [Indexed: 02/07/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is currently the third most common cause of global mortality. Acute exacerbations of COPD frequently necessitate hospital admission to enable more intensive therapy, incurring significant healthcare costs. COPD exacerbations are also associated with accelerated lung function decline and increased risk of mortality. Until recently, bacterial pathogens were believed to be responsible for the majority of disease exacerbations. However, with the advent of culture-independent molecular diagnostic techniques it is now estimated that viruses are detected during half of all COPD exacerbations and are associated with poorer clinical outcomes. Human rhinovirus, respiratory syncytial virus and influenza are the most commonly detected viruses during exacerbation. The role of persistent viral infection (adenovirus) has also been postulated as a potential pathogenic mechanism in COPD. Viral pathogens may play an important role in driving COPD progression by acting as triggers for exacerbation and subsequent lung function decline whilst the role of chronic viral infection remains a plausible hypothesis that requires further evaluation. There are currently no effective antiviral strategies for patients with COPD. Herein, we focus on the current understanding of the cellular and molecular mechanisms of respiratory viral infection in COPD.
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Affiliation(s)
- Dermot Linden
- Airway Innate Immunity Research Group (AiiR), Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK
| | - Hong Guo-Parke
- Airway Innate Immunity Research Group (AiiR), Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK
| | - Peter V Coyle
- The Regional Virus Laboratory, Belfast Trust, Belfast, UK
| | - Derek Fairley
- The Regional Virus Laboratory, Belfast Trust, Belfast, UK
| | - Danny F McAuley
- Airway Innate Immunity Research Group (AiiR), Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK
| | - Clifford C Taggart
- Airway Innate Immunity Research Group (AiiR), Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK
| | - Joe Kidney
- Dept of Respiratory Medicine, Mater Hospital Belfast, Belfast, UK
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27
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Agus A, Phair G, Page VJ, McAuley DF. Simvastatin for the prevention and treatment of delirium in critically ill, mechanically ventilated patients (MoDUS): a cost-effectiveness analysis. Lancet Respir Med 2018; 6:e9-e10. [PMID: 29508709 DOI: 10.1016/s2213-2600(18)30070-5] [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] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 02/06/2018] [Accepted: 02/06/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Ashley Agus
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK.
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK
| | - Valerie J Page
- Department of Anaesthesia, Watford General Hospital, Watford, UK; Faculty of Medicine, Imperial College London, South Kensington Campus, London, UK
| | - Danny F McAuley
- Regional Intensive Care Unit, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK; Centre for Infection and Immunity, Queen's University of Belfast, Belfast, UK
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28
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Hamid U, Krasnodembskaya A, Fitzgerald M, Shyamsundar M, Kissenpfennig A, Scott C, Lefrancais E, Looney MR, Verghis R, Scott J, Simpson AJ, McNamee J, McAuley DF, O'Kane CM. Aspirin reduces lipopolysaccharide-induced pulmonary inflammation in human models of ARDS. Thorax 2017; 72:971-980. [PMID: 28082531 PMCID: PMC5858553 DOI: 10.1136/thoraxjnl-2016-208571] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [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: 03/01/2016] [Revised: 11/24/2016] [Accepted: 12/03/2016] [Indexed: 12/15/2022]
Abstract
RATIONALE Platelets play an active role in the pathogenesis of acute respiratory distress syndrome (ARDS). Animal and observational studies have shown aspirin's antiplatelet and immunomodulatory effects may be beneficial in ARDS. OBJECTIVE To test the hypothesis that aspirin reduces inflammation in clinically relevant human models that recapitulate pathophysiological mechanisms implicated in the development of ARDS. METHODS Healthy volunteers were randomised to receive placebo or aspirin 75 or 1200 mg (1:1:1) for seven days prior to lipopolysaccharide (LPS) inhalation, in a double-blind, placebo-controlled, allocation-concealed study. Bronchoalveolar lavage (BAL) was performed 6 hours after inhaling 50 µg of LPS. The primary outcome measure was BAL IL-8. Secondary outcome measures included markers of alveolar inflammation (BAL neutrophils, cytokines, neutrophil proteases), alveolar epithelial cell injury, systemic inflammation (neutrophils and plasma C-reactive protein (CRP)) and platelet activation (thromboxane B2, TXB2). Human lungs, perfused and ventilated ex vivo (EVLP) were randomised to placebo or 24 mg aspirin and injured with LPS. BAL was carried out 4 hours later. Inflammation was assessed by BAL differential cell counts and histological changes. RESULTS In the healthy volunteer (n=33) model, data for the aspirin groups were combined. Aspirin did not reduce BAL IL-8. However, aspirin reduced pulmonary neutrophilia and tissue damaging neutrophil proteases (Matrix Metalloproteinase (MMP)-8/-9), reduced BAL concentrations of tumour necrosis factor α and reduced systemic and pulmonary TXB2. There was no difference between high-dose and low-dose aspirin. In the EVLP model, aspirin reduced BAL neutrophilia and alveolar injury as measured by histological damage. CONCLUSIONS These are the first prospective human data indicating that aspirin inhibits pulmonary neutrophilic inflammation, at both low and high doses. Further clinical studies are indicated to assess the role of aspirin in the prevention and treatment of ARDS. TRIAL REGISTRATION NUMBER NCT01659307 Results.
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Affiliation(s)
- U Hamid
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - A Krasnodembskaya
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - M Fitzgerald
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - M Shyamsundar
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - A Kissenpfennig
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - C Scott
- School of Pharmacy, Queen's University of Belfast, Belfast, Northern Ireland, UK
| | - E Lefrancais
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - M R Looney
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - R Verghis
- Northern Ireland Clinical Trials Unit, Royal Victoria Hospital, Belfast, UK
| | - J Scott
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle-upon Tyne, UK
| | - A J Simpson
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle-upon Tyne, UK
| | - J McNamee
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - D F McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK.,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - C M O'Kane
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK
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29
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Rose L, McGinlay M, Amin R, Burns KE, Connolly B, Hart N, Jouvet P, Katz S, Leasa D, Mawdsley C, McAuley DF, Schultz MJ, Blackwood B. Variation in Definition of Prolonged Mechanical Ventilation. Respir Care 2017; 62:1324-1332. [PMID: 28611229 DOI: 10.4187/respcare.05485] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Consistency of definitional criteria for terminology applied to describe subject cohorts receiving mechanical ventilation within ICU and post-acute care settings is important for understanding prevalence, risk stratification, effectiveness of interventions, and projections for resource allocation. Our objective was to quantify the application and definition of terms for prolonged mechanical ventilation. We conducted a scoping review of studies (all designs except single-case study) reporting a study population (adult and pediatric) using the term prolonged mechanical ventilation or a synonym. We screened 5,331 references, reviewed 539 full-text references, and excluded 120. Of the 419 studies (representing 38 countries) meeting inclusion criteria, 297 (71%) reported data on a heterogeneous subject cohort, and 66 (16%) included surgical subjects only (46 of those 66, 70% cardiac surgery). Other studies described COPD (16, 4%), trauma (22, 5%), neuromuscular (17, 4%), and sepsis (1, 0.2%) cohorts. A total of 741 terms were used to refer to the 419 study cohorts. The most common terms were: prolonged mechanical ventilation (253, 60%), admission to specialized unit (107, 26%), and long-term mechanical ventilation (79, 19%). Some authors (282, 67%) defined their cohorts based on duration of mechanical ventilation, with 154 studies (55%) using this as the sole criterion. We identified 37 different durations of ventilation ranging from 5 h to 1 y, with > 21 d being the most common (28 of 282, 7%). For studies describing a surgical cohort, minimum ventilation duration required for inclusion was ≥ 24 h for 20 of 66 studies (30%). More than half of all studies (237, 57%) did not provide a reason/rationale for definitional criteria used, with only 28 studies (7%) referring to a consensus definition. We conclude that substantial variation exists in the terminology and definitional criteria for cohorts of subjects receiving prolonged mechanical ventilation. Standardization of terminology and definitional criteria is required for study data to be maximally informative.
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Affiliation(s)
- Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre; the Lawrence S Bloomberg Faculty of Nursing and the Interdepartmental Division of Critical Care Medicine, University of Toronto; and the Provincial Centre of Weaning Excellence, Toronto East General Hospital, Toronto, Ontario, Canada.
| | | | - Reshma Amin
- SickKids Hospital and the Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Karen Ea Burns
- Saint Michael's Hospital; the Li Ka Shing Knowledge Institute; and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bronwen Connolly
- Lane Fox Respiratory Unit, St Thomas's Hospital, Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Nicholas Hart
- Lane Fox Respiratory Unit, St Thomas's Hospital, Guy's and St Thomas's NHS Foundation Trust, and King's College London, London, United Kingdom
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, and the University of Montreal, Montreal, Quebec, Canada
| | - Sherri Katz
- Department of Respirology, Children's Hospital of Eastern Ontario, and the CHEO Research Institute, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David Leasa
- Critical Care Western and London Health Sciences Centre and Western University, London, Ontario, Canada
| | - Cathy Mawdsley
- Critical Care Western and London Health Sciences Centre, London, Ontario, Canada
| | - Danny F McAuley
- Royal Victoria Hospital and the Centre for Experimental Medicine, Queen's University, Belfast, Northern Ireland
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam-Zuidoost, The Netherlands
| | - Bronagh Blackwood
- Centre for Experimental Medicine, Queen's University, Belfast, Northern Ireland
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30
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Agus A, Hulme C, Verghis RM, McDowell C, Jackson C, O'Kane CM, Laffey JG, McAuley DF. Simvastatin for patients with acute respiratory distress syndrome: long-term outcomes and cost-effectiveness from a randomised controlled trial. Crit Care 2017; 21:108. [PMID: 28511660 PMCID: PMC5434552 DOI: 10.1186/s13054-017-1695-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/02/2017] [Indexed: 11/17/2022] Open
Abstract
Background Simvastatin therapy for patients with acute respiratory distress syndrome (ARDS) has been shown to be safe and associated with minimal adverse effects, but it does not improve clinical outcomes. The aim of this research was to report on mortality and cost-effectiveness of simvastatin in patients with ARDS at 12 months. Methods This was a cost-utility analysis alongside a multicentre, double-blind, randomised controlled trial carried out in the UK and Ireland. Five hundred and forty intubated and mechanically ventilated patients with ARDS were randomly assigned (1:1) to receive once-daily simvastatin (at a dose of 80 mg) or identical placebo tablets enterally for up to 28 days. Results Mortality was lower in the simvastatin group (31.8%, 95% confidence interval (CI) 26.1–37.5) compared to the placebo group (37.3%, 95% CI 31.6–43.0) at 12 months, although this was not significant. Simvastatin was associated with statistically significant quality-adjusted life year (QALY) gain (incremental QALYs 0.064, 95% CI 0.002–0.127) compared to placebo. Simvastatin was also less costly (incremental total costs –£3601, 95% CI –8061 to 859). At a willingness-to-pay threshold of £20,000 per QALY, the probability of simvastatin being cost-effective was 99%. Sensitivity analyses indicated that the results were robust to changes in methodological assumptions with the probability of cost-effectiveness never dropping below 90%. Conclusion Simvastatin was found to be cost-effective for the treatment of ARDS, being associated with both a significant QALY gain and a cost saving. There was no significant reduction in mortality at 12 months, Trial registration ISRCTN, 88244364. Registered 26 November 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1695-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Agus
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK.
| | - C Hulme
- Academic Unit of Health Economics, University of Leeds, Charles Thackrah Building, Clarendon Road, Leeds, LS2 9LJ, UK
| | - R M Verghis
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK.,Centre for Infection and Immunity, Queen's University of Belfast, Belfast, BT9 7AE, UK
| | - C McDowell
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK
| | - C Jackson
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK
| | - C M O'Kane
- Centre for Infection and Immunity, Queen's University of Belfast, Belfast, BT9 7AE, UK
| | - J G Laffey
- Department of Anaesthesia, School of Medicine, HRB Galway Clinical Research Facility, Clinical Sciences Institute, National University of Ireland, Galway, Ireland.,Department of Anesthesia, Centre for Critical Care Research, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - D F McAuley
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK.,Centre for Infection and Immunity, Queen's University of Belfast, Belfast, BT9 7AE, UK.,Regional Intensive Care Unit, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK
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31
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Luo Y, McLean DTF, Linden GJ, McAuley DF, McMullan R, Lundy FT. The Naturally Occurring Host Defense Peptide, LL-37, and Its Truncated Mimetics KE-18 and KR-12 Have Selected Biocidal and Antibiofilm Activities Against Candida albicans, Staphylococcus aureus, and Escherichia coli In vitro. Front Microbiol 2017; 8:544. [PMID: 28408902 PMCID: PMC5374219 DOI: 10.3389/fmicb.2017.00544] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 03/15/2017] [Indexed: 12/03/2022] Open
Abstract
Amongst the recognized classes of naturally occurring antimicrobials, human host defense peptides are an important group with an advantage (given their source) that they should be readily translatable to medicinal products. It is also plausible that truncated versions will display some of the biological activities of the parent peptide, with the benefit that they are less costly to synthesize using solid-phase chemistry. The host defense peptide, LL-37, and two truncated mimetics, KE-18 and KR-12, were tested for their inhibitory effects and antibiofilm properties against Candida albicans, Staphylococcus aureus, and Escherichia coli, microorganisms commonly implicated in biofilm-related infections such as ventilator-associated pneumonia (VAP). Using in silico prediction tools, the truncated peptides KE-18 and KR-12 were selected for minimum inhibitory concentration (MIC) and antibiofilm testing on the basis of their favorable cationicity, hydrophobic ratio, and amphipathicity compared with the parent peptide. Two methods were analyzed for determining peptide efficacy against biofilms; a crystal violet assay and an XTT [2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide] assay. The biocidal activities (measured by MIC) and antibiofilm activities (measured by a crystal violet assay) appeared to be independent. LL-37 had no biocidal action against C. albicans (MIC > 250 μg/ml) but significant effects in both biofilm-prevention and biofilm-inhibition assays. KE-18 and KR-12 yielded superior MIC values against all three microorganisms. Only KE-18 had a significant effect in the biofilm-prevention assay, which persisted even at sub-MICs. Neither of the truncated peptides were active in the biofilm-inhibition assay. KE-18 was shown to bind lipopolysaccharide as effectively as LL-37 and to bind lipoteichoic acid more effectively. None of the peptides showed hemolytic activity against human erythrocytes at the concentrations tested. KE-18 should be considered for further development as a natural peptide-derived therapeutic for prevention of multi-species biofilm-related infections such as VAP.
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Affiliation(s)
- Yu Luo
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University BelfastBelfast, UK
| | - Denise T F McLean
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University BelfastBelfast, UK
| | - Gerard J Linden
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University BelfastBelfast, UK
| | - Danny F McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University BelfastBelfast, UK
| | - Ronan McMullan
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University BelfastBelfast, UK
| | - Fionnuala T Lundy
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University BelfastBelfast, UK
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Abstract
BACKGROUND Severe sepsis and septic shock are leading causes of death in the intensive care unit (ICU), despite advances in the treatment of patients with severe sepsis and septic shock, including early recognition, appropriate treatment with antibiotics and support of organs that may have been affected by the illness. High-volume haemofiltration (HVHF) is a blood purification technique that may improve outcomes in severe sepsis or septic shock. The technique of HVHF has evolved from renal replacement therapies used in the ICU to treat critically ill patients with acute kidney injury (AKI). This review was first published in 2013 and was updated in 2016. OBJECTIVES To investigate whether HVHF improves outcomes in critically ill adults admitted to the intensive care unit with severe sepsis or septic shock. The primary outcome of this systematic review is patient mortality; secondary outcomes include duration of stay, severity of organ dysfunction and adverse events. SEARCH METHODS For this updated version, we extended searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American Caribbean Health Sciences Literature (LILACS), Web of Science and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to 31 December 2015. The original search was performed in 2011. We also searched trials registers. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-randomized trials comparing HVHF or high-volume haemodiafiltration versus standard or usual dialysis therapy, as well as RCTs and quasi-randomized trials comparing HVHF or high-volume haemodiafiltration versus no similar dialysis therapy. These studies involved adults treated in critical care units. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data and assessed trial quality. We sought additional information from trialists as required. MAIN RESULTS We included four randomized trials involving 200 participants. Owing to small numbers of studies and participants, it was not possible to combine data for all outcomes. Two trials reported 28-day mortality, and one trial reported hospital mortality; in the third trial, the number of deaths stated did not match the quoted mortality rates. The pooled risk ratio (95% confidence interval) for 28-day mortality associated with HVHF was 0.89 (0.60 to 1.32, two trials, 146 participants, low-quality evidence). One study (137 participants, low-quality evidence) reported length of stay in the ICU. Two trials (170 participants, low-quality evidence) reported organ dysfunction, but we could not pool results owing to reporting differences. Three studies (189 participants, low-quality evidence) reported on haemodynamic changes, but we could not pool results owing to reporting differences. Investigators reported no adverse events. Overall, the included studies had low risk of bias. AUTHORS' CONCLUSIONS Investigators reported no adverse effects of HVHF (low-quality evidence). The results of this meta-analysis show that very few studies have been conducted to investigate the use of HVHF in critically ill patients with severe sepsis or septic shock (four studies, 201 participants, low-quality evidence). Researchers should consider additional randomized controlled trials that are large and multi-centred and have clinically relevant outcome measures. The cost-effectiveness of HVHF should also be studied. .
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Affiliation(s)
- Emma MJ Borthwick
- Belfast City HospitalRegional Nephrology UnitBelfastNorthern IrelandUKBT9 7AB
| | - Christopher J Hill
- Belfast City HospitalRegional Nephrology UnitBelfastNorthern IrelandUKBT9 7AB
| | | | - Alexander P Maxwell
- Belfast City HospitalRegional Nephrology UnitBelfastNorthern IrelandUKBT9 7AB
| | - Danny F McAuley
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesWellcome‐Wolfson Building97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
| | - Bronagh Blackwood
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesWellcome‐Wolfson Building97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
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33
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McNamee JJ, Gillies MA, Barrett NA, Agus AM, Beale R, Bentley A, Bodenham A, Brett SJ, Brodie D, Finney SJ, Gordon AJ, Griffiths M, Harrison D, Jackson C, McDowell C, McNally C, Perkins GD, Tunnicliffe W, Vuylsteke A, Walsh TS, Wise MP, Young D, McAuley DF. pRotective vEntilation with veno-venouS lung assisT in respiratory failure: A protocol for a multicentre randomised controlled trial of extracorporeal carbon dioxide removal in patients with acute hypoxaemic respiratory failure. J Intensive Care Soc 2016; 18:159-169. [PMID: 28979565 DOI: 10.1177/1751143716681035] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 12/25/2022] Open
Abstract
One of the few interventions to demonstrate improved outcomes for acute hypoxaemic respiratory failure is reducing tidal volumes when using mechanical ventilation, often termed lung protective ventilation. Veno-venous extracorporeal carbon dioxide removal (vv-ECCO2R) can facilitate reducing tidal volumes. pRotective vEntilation with veno-venouS lung assisT (REST) is a randomised, allocation concealed, controlled, open, multicentre pragmatic trial to determine the clinical and cost-effectiveness of lower tidal volume mechanical ventilation facilitated by vv-ECCO2R in patients with acute hypoxaemic respiratory failure. Patients requiring intubation and mechanical ventilation for acute hypoxaemic respiratory failure will be randomly allocated to receive either vv-ECCO2R and lower tidal volume mechanical ventilation or standard care with stratification by recruitment centre. There is a need for a large randomised controlled trial to establish whether vv-ECCO2R in acute hypoxaemic respiratory failure can allow the use of a more protective lung ventilation strategy and is associated with improved patient outcomes.
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Affiliation(s)
- J J McNamee
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK.,Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - M A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.,Chief Scientists Office NHS Research Scotland, Clydebank, UK
| | - N A Barrett
- Guy's and St Thomas' NHS Foundation Trust, King's College London, UK.,King's Health Partners Academic Health Science Centre, London, UK
| | - A M Agus
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - R Beale
- Guy's and St Thomas' NHS Foundation Trust, King's College London, UK.,King's Health Partners Academic Health Science Centre, London, UK
| | - A Bentley
- Acute Intensive Care Unit, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK.,Centre for Respiratory Medicine & Allergy, University of Manchester, UK
| | - A Bodenham
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, UK
| | - S J Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
| | - D Brodie
- Columbia College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, USA
| | - S J Finney
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - A J Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - M Griffiths
- National Heart & Lung Institute, Imperial College, London, UK.,National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - D Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - C Jackson
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - C McDowell
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - C McNally
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - G D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,Heart of England NHS Foundation Trust, Birmingham, UK
| | - W Tunnicliffe
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - A Vuylsteke
- Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - T S Walsh
- Anaesthetics, Critical Care and Pain Medicine, School of Clinical Sciences, College of Medicine, Edinburgh University, Edinburgh, UK
| | - M P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - D Young
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - D F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK.,Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
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Conway Morris A, Gadsby N, McKenna JP, Hellyer TP, Dark P, Singh S, Walsh TS, McAuley DF, Templeton K, Simpson AJ, McMullan R. 16S pan-bacterial PCR can accurately identify patients with ventilator-associated pneumonia. Thorax 2016; 72:1046-1048. [PMID: 27974525 PMCID: PMC5738539 DOI: 10.1136/thoraxjnl-2016-209065] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/10/2016] [Accepted: 10/01/2016] [Indexed: 11/23/2022]
Abstract
Ventilator-associated pneumonia (VAP) remains a challenge to intensive care units, with secure diagnosis relying on microbiological cultures that take up to 72 hours to provide a result. We sought to derive and validate a novel, real-time 16S rRNA gene PCR for rapid exclusion of VAP. Bronchoalveolar lavage (BAL) was obtained from two independent cohorts of patients with suspected VAP. Patients were recruited in a 2-centre derivation cohort and a 12-centre confirmation cohort. Confirmed VAP was defined as growth of >104 colony forming units/ml on semiquantitative culture and compared with a 16S PCR assay. Samples were tested from 67 patients in the derivation cohort, 10 (15%) of whom had confirmed VAP. Using cycles to cross threshold (Ct) values as the result of the 16S PCR test, the area under the receiver operating characteristic (ROC) curve (AUROC) was 0.94 (95% CI 0.86 to 1.0, p<0.0001). Samples from 92 patients were available from the confirmation cohort, 26 (28%) of whom had confirmed VAP. The AUROC for Ct in this cohort was 0.89 (95% CI 0.83 to 0.95, p<0.0001). This study has derived and assessed the diagnostic accuracy of a novel application for 16S PCR. This suggests that 16S PCR in BAL could be used as a rapid test in suspected VAP and may allow better stewardship of antibiotics.
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Affiliation(s)
- Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK.,Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Naomi Gadsby
- Department of Clinical Microbiology, NHS Lothian, Edinburgh, UK
| | - James P McKenna
- Department of Microbiology, Belfast Health & Social Care Trust, Belfast, UK
| | - Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Paul Dark
- Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.,Intensive Care Unit, Salford Royal NHS Foundation Trust, Greater Manchester, UK
| | - Suveer Singh
- Intensive Care Unit, Chelsea and Westminster Hospital, Imperial College London, London, UK
| | - Timothy S Walsh
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Danny F McAuley
- Centre for Infection and Immunity, Queen's University Belfast, UK.,Intensive Care Unit, Royal Victoria Infirmary, Belfast, UK
| | - Kate Templeton
- Department of Clinical Microbiology, NHS Lothian, Edinburgh, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Ronan McMullan
- Department of Microbiology, Belfast Health & Social Care Trust, Belfast, UK.,Centre for Infection and Immunity, Queen's University Belfast, UK
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35
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Morrison TJ, Jackson MV, O’Kane C, McAuley DF, Krasnodembskaya A. S80 Mesenchymal stromal cells (MSC) modulate human macrophages in acute respiratory distress syndrome (ARDS) via secretion of extracellular vesicles (EV) which enhance oxidative phosphorylation and regulate jak/stat signalling. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.86] [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: 11/03/2022]
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McDowell K, Bradley JM, McAuley DF, Blackwood B, O’Neill B. S14 Patients’ perceptions of an exercise programme delivered following discharge from hospital after critical illness (the revive trial). Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.20] [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: 11/04/2022]
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Fitzgerald M, McAuley DF, O’Kane CM. S81 Oncostatin m is a novel mediator of human pulmonary endothelial chemokine and protease activity in the lung in ARDS. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.87] [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: 11/03/2022]
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Luo Y, Bolt HL, Eggimann GA, McAuley DF, McMullan R, Curran T, Zhou M, Jahoda PCAB, Cobb SL, Lundy FT. Peptoid Efficacy against Polymicrobial Biofilms Determined by Using Propidium Monoazide-Modified Quantitative PCR. Chembiochem 2016; 18:111-118. [PMID: 27900840 PMCID: PMC6680226 DOI: 10.1002/cbic.201600381] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Indexed: 01/07/2023]
Abstract
Biofilms containing Candida albicans are responsible for a wide variety of clinical infections. The protective effects of the biofilm matrix, the low metabolic activity of microorganisms within a biofilm and their high mutation rate, significantly enhance the resistance of biofilms to conventional antimicrobial treatments. Peptoids are peptide‐mimics that share many features of host defence antimicrobial peptides but have increased resistance to proteases and therefore have better stability in vivo. The activity of a library of peptoids was tested against monospecies and polymicrobial bacterial/fungal biofilms. Selected peptoids showed significant bactericidal and fungicidal activity against the polymicrobial biofilms. This coupled with low cytotoxicity suggests that peptoids could offer a new option for the treatment of clinically relevant polymicrobial infections.
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Affiliation(s)
- Yu Luo
- Centre for Experimental Medicine, The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Hannah L Bolt
- Durham University, Department of Chemistry, Biophysical Sciences Institute, South Road, Durham, DH1 3LE, UK
| | - Gabriela A Eggimann
- Durham University, Department of Chemistry, Biophysical Sciences Institute, South Road, Durham, DH1 3LE, UK
| | - Danny F McAuley
- Centre for Experimental Medicine, The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Ronan McMullan
- Centre for Experimental Medicine, The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Tanya Curran
- Regional Virus Laboratory, Kelvin Building, Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, BT12 6BA, UK
| | - Mei Zhou
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | | | - Steven L Cobb
- Durham University, Department of Chemistry, Biophysical Sciences Institute, South Road, Durham, DH1 3LE, UK
| | - Fionnuala T Lundy
- Centre for Experimental Medicine, The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
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Williams AE, José RJ, Mercer PF, Brealey D, Parekh D, Thickett DR, O'Kane C, McAuley DF, Chambers RC. Evidence for chemokine synergy during neutrophil migration in ARDS. Thorax 2016; 72:66-73. [PMID: 27496101 PMCID: PMC5329051 DOI: 10.1136/thoraxjnl-2016-208597] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/07/2016] [Accepted: 07/02/2016] [Indexed: 01/05/2023]
Abstract
Background Acute respiratory distress syndrome (ARDS) is a life-threatening condition characterised by pulmonary oedema, respiratory failure and severe inflammation. ARDS is further characterised by the recruitment of neutrophils into the lung interstitium and alveolar space. Objectives The factors that regulate neutrophil infiltration into the inflamed lung and our understanding of the pathomechanisms in ARDS remain incomplete. This study aimed at determining the role of the chemokine (C-C motif) ligand (CCL)2 and CCL7 in ARDS. Methods CCL2 and CCL7 protein levels were measured in bronchoalveolar lavage (BAL) fluid obtained from lipopolysaccharide(LPS)-challenged human volunteers and two separate cohorts of patients with ARDS. Neutrophil chemotaxis to ARDS BAL fluid was evaluated and the contribution of each was assessed and compared with chemokine (C-X-C motif) ligand 8 (CXCL8). Chemokine receptor expression on neutrophils from blood or BAL fluid of patients with ARDS was analysed by flow cytometry. Results CCL2 and CCL7 were significantly elevated in BAL fluid recovered from LPS-challenged volunteers and patients with ARDS. BAL fluid from patients with ARDS was highly chemotactic for human neutrophils and neutralising either CCL2 or CCL7 attenuated the neutrophil chemotactic response. Moreover, CCL2 and CCL7 synergised with CXCL8 to promote neutrophil migration. Furthermore, neutrophils isolated from the blood or BAL fluid differentially regulated the cell surface expression of chemokine (C-X-C motif) receptor 1 and C-C chemokine receptor type 2 during ARDS. Conclusion This study highlights important inflammatory chemokines involved in regulating neutrophil migration, which may have potential value as therapeutic targets for the treatment of ARDS.
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Affiliation(s)
- Andrew E Williams
- Division of Medicine, Centre for Inflammation and Tissue Repair, UCL Respiratory, Rayne Institute, University College London (UCL), London, UK
| | - Ricardo J José
- Division of Medicine, Centre for Inflammation and Tissue Repair, UCL Respiratory, Rayne Institute, University College London (UCL), London, UK
| | - Paul F Mercer
- Division of Medicine, Centre for Inflammation and Tissue Repair, UCL Respiratory, Rayne Institute, University College London (UCL), London, UK
| | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College Hospital, London, UK
| | - Dhruv Parekh
- Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
| | - David R Thickett
- Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
| | - Cecelia O'Kane
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University of Belfast and Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Danny F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University of Belfast and Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Rachel C Chambers
- Division of Medicine, Centre for Inflammation and Tissue Repair, UCL Respiratory, Rayne Institute, University College London (UCL), London, UK
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Fitzgerald M, Shyamsundar M, McNamee JJ, Thickett DR, O’Kane CM, McAuley DF. S67 Vitamin D deficiency drives pulmonary inflammation in a human model of the acute respiratory distress syndrome induced by inhaled lipopolysaccharide in healthy volunteers. Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Jackson MV, Morrison TJ, O’Kane CM, McAuley DF, Krasnodembskaya AD. T3 Mitochondrial transfer is an important mechanism by which Mesenchymal Stromal Cells (MSC) facilitate macrophage phagocytosis in thein vitroandin vivomodels of Acute Respiratory Distress Syndrome (ARDS). Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Morrison T, McAuley DF, Krasnodembskaya A. Mesenchymal stromal cells for treatment of the acute respiratory distress syndrome: The beginning of the story. J Intensive Care Soc 2015; 16:320-329. [PMID: 28979439 PMCID: PMC5606462 DOI: 10.1177/1751143715586420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
In spite of decades of research, the acute respiratory distress syndrome (ARDS) continues to have an unacceptably high mortality and morbidity. Mesenchymal stromal cells (MSCs) present a promising candidate for the treatment of this condition and have demonstrated benefit in preclinical models. MSCs, which are a topic of growing interest in many inflammatory disorders, have already progressed to early phase clinical trials in ARDS. While a number of their mechanisms of effect have been elucidated, a better understanding of the complex actions of these cells may pave the way for MSC modifications, which might enable more effective translation into clinical practice.
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Affiliation(s)
- J E Millar
- Department of Anaesthesia, Critical Care & Pain, University of Glasgow, Glasgow, UK
| | - J F Fraser
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - D F McAuley
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
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Affiliation(s)
- E L Cunningham
- Centre for Public Health, Queen's University Belfast, Block B, Institute Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA
| | - A P Passmore
- Centre for Public Health, Queen's University Belfast, Block B, Institute Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA
| | - D F McAuley
- Centre for Public Health, Queen's University Belfast, Block B, Institute Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA
| | - B McGuinness
- Centre for Public Health, Queen's University Belfast, Block B, Institute Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA
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Glasgow AMA, Small DM, Scott A, McLean DT, Camper N, Hamid U, Hegarty S, Parekh D, O'Kane C, Lundy FT, McNally P, Elborn JS, McAuley DF, Weldon S, Taggart CC. A role for whey acidic protein four-disulfide-core 12 (WFDC12) in the regulation of the inflammatory response in the lung. Thorax 2015; 70:426-32. [PMID: 25770093 DOI: 10.1136/thoraxjnl-2014-206488] [Citation(s) in RCA: 11] [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: 10/24/2014] [Accepted: 02/10/2015] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Secretory leucocyte protease inhibitor and elafin are members of the whey acidic protein (WAP), or WAP four disulfide-core (WFDC), family of proteins and have multiple contributions to innate defence including inhibition of neutrophil serine proteases and inhibition of the inflammatory response to lipopolysaccharide (LPS). This study aimed to explore potential activities of WFDC12, a previously uncharacterised WFDC protein expressed in the lung. METHODS Recombinant expression and purification of WFDC12 were optimised in Escherichia coli. Antiprotease, antibacterial and immunomodulatory activities of recombinant WFDC12 were evaluated and levels of endogenous WFDC12 protein were characterised by immunostaining and ELISA. RESULTS Recombinant WFDC12 inhibited cathepsin G, but not elastase or proteinase-3 activity. Monocytic cells pretreated with recombinant WFDC12 before LPS stimulation produced significantly lower levels of the pro-inflammatory cytokines interleukin-8 and monocyte chemotactic protein-1 compared with cells stimulated with LPS alone. Recombinant WFDC12 became conjugated to fibronectin in a transglutaminase-mediated reaction and retained antiprotease activity. In vivo WFDC12 expression was confirmed by immunostaining of human lung tissue sections. WFDC12 levels in human bronchoalveolar lavage fluid from healthy and lung-injured patients were quantitatively compared, showing WFDC12 to be elevated in both patients with acute respiratory distress syndrome and healthy subjects treated with LPS, relative to healthy controls. CONCLUSIONS Together, these results suggest a role for this lesser known WFDC protein in the regulation of lung inflammation.
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Affiliation(s)
- Arlene M A Glasgow
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Donna M Small
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Aaron Scott
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Denise T McLean
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Nicolas Camper
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Umar Hamid
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Shauna Hegarty
- Department of Pathology, Royal Victoria Hospital, Belfast, UK
| | - Dhruv Parekh
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Cecilia O'Kane
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Fionnuala T Lundy
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Paul McNally
- Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - J Stuart Elborn
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Danny F McAuley
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Sinéad Weldon
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Clifford C Taggart
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
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Rose L, Schultz MJ, Cardwell CR, Jouvet P, McAuley DF, Blackwood B. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children: a cochrane systematic review and meta-analysis. Crit Care 2015; 19:48. [PMID: 25887887 PMCID: PMC4344786 DOI: 10.1186/s13054-015-0755-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 01/19/2015] [Indexed: 12/01/2022] Open
Abstract
Introduction Automated weaning systems may improve adaptation of mechanical support for a patient’s ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. Our objective was to compare mechanical ventilator weaning duration for critically ill adults and children when managed with automated systems versus non-automated strategies. Secondary objectives were to determine differences in duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), mortality, and adverse events. Methods Electronic databases were searched to 30 September 2013 without language restrictions. We also searched conference proceedings; trial registration websites; and article reference lists. Two authors independently extracted data and assessed risk of bias. We combined data using random-effects modelling. Results We identified 21 eligible trials totalling 1,676 participants. Pooled data from 16 trials indicated that automated systems reduced the geometric mean weaning duration by 30% (95% confidence interval (CI) 13% to 45%), with substantial heterogeneity (I2 = 87%, P <0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PS™ (28%, 95% CI 7% to 49%) but not with surgical populations or using other systems. Automated systems reduced ventilation duration with no heterogeneity (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of effect on mortality, hospital LOS, reintubation, self-extubation and non-invasive ventilation following extubation. Automated systems reduced prolonged mechanical ventilation and tracheostomy. Overall quality of evidence was high. Conclusions Automated systems may reduce weaning and ventilation duration and ICU stay. Due to substantial trial heterogeneity an adequately powered, high quality, multi-centre randomized controlled trial is needed. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0755-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada. .,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, Ontario, M5T IP8, Canada. .,Provincial Centre of Weaning Excellence, Toronto East General Hospital, Toronto, Canada. .,Li Ka Shing Institute, St Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada. .,West Park Healthcare Centre, University of Toronto, 155 College St, Toronto, Ontario, M5T IP8, Canada.
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands.
| | - Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, University Rd, Belfast, BT7 1NN, UK.
| | - Philippe Jouvet
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
| | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Centre for Infection and Immunity, Queen's University of Belfast, University Rd, Belfast, BT7 1NN, UK.
| | - Bronagh Blackwood
- Centre for Infection and Immunity, School of Medicine, Dentistry & Biomedical Sciences, Queen's University Belfast, University Rd, Belfast, BT7 1NN, UK.
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Cunningham EL, Passmore AP, McAuley DF, McGuinness B. Reciting the months of the year backwards: what is a 'normal' score? Age Ageing 2015. [DOI: 10.1093/ageing/el_719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - AP Passmore
- Clinical Research Fellow, Queen's University Belfast
| | - DF McAuley
- Clinical Research Fellow, Queen's University Belfast
| | - B McGuinness
- Clinical Research Fellow, Queen's University Belfast
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Browne E, Hellyer TP, Baudouin SV, Conway Morris A, Linnett V, McAuley DF, Perkins GD, Simpson AJ. A national survey of the diagnosis and management of suspected ventilator-associated pneumonia. BMJ Open Respir Res 2014; 1:e000066. [PMID: 25553248 PMCID: PMC4275666 DOI: 10.1136/bmjresp-2014-000066] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/10/2014] [Accepted: 11/12/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) affects up to 20% of patients admitted to intensive care units (ICU). It is associated with increased morbidity, mortality and healthcare costs. Despite published guidelines, variability in diagnosis and management exists, the extent of which remains unclear. We sought to characterise consultant opinions surrounding diagnostic and management practice for VAP in the UK. METHODS An online survey was sent to all consultant members of the UK Intensive Care Society (n=∼1500). Data were collected regarding respondents' individual practice in the investigation and management of suspected VAP including use of diagnostic criteria, microbiological sampling, chest X-ray (CXR), bronchoscopy and antibiotic treatments. RESULTS 339 (23%) responses were received from a broadly representative spectrum of ICU consultants. All respondents indicated that microbiological confirmation should be sought, the majority (57.8%) stating they would take an endotracheal aspirate prior to starting empirical antibiotics. Microbiology reporting services were described as qualitative only by 29.7%. Only 17% of respondents had access to routine reporting of CXRs by a radiologist. Little consensus exists regarding technique for bronchoalveolar lavage (BAL) with the reported volume of saline used ranging from 5 to 500 mL. 24.5% of consultants felt inadequately trained in bronchoscopy. CONCLUSIONS There is wide variability in the approach to diagnosis and management of VAP among UK consultants. Such variability challenges the reliability of the diagnosis of VAP and its reported incidence as a performance indicator in healthcare systems. The data presented suggest increased radiological and microbiological support, and standardisation of BAL technique, might improve this situation.
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Affiliation(s)
- Emma Browne
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Simon V Baudouin
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Andrew Conway Morris
- MRC Centre for Inflammation Research, University of Edinburgh, and Critical Care NHS Lothian , Edinburgh , UK
| | - Vanessa Linnett
- Queen Elizabeth Hospital, Gateshead Health NHS Trust , Gateshead , UK
| | - Danny F McAuley
- Centre for Infection and Immunity, Queen's University Belfast and Regional Intensive Care Unit, Royal Victoria Hospital Belfast , Belfast , Northern Ireland
| | - Gavin D Perkins
- Warwick Medical School and Heart of England NHS Foundation Trust , Birmingham , UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
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Hamid UI, Conlon J, Spence S, Krasnodembskaya A, Kissenpfennig A, McAuley DF, O'Kane CM. 0995. Aspirin reduces neutrophilic pulmonary inflammation in a human model of acute respiratory distress syndrome induced by inhaled lipopolysaccharide. Intensive Care Med Exp 2014. [PMCID: PMC4797928 DOI: 10.1186/2197-425x-2-s1-p80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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50
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Weldon S, McNally P, McAuley DF, Oglesby IK, Wohlford-Lenane CL, Bartlett JA, Scott CJ, McElvaney NG, Greene CM, McCray PB, Taggart CC. miR-31 dysregulation in cystic fibrosis airways contributes to increased pulmonary cathepsin S production. Am J Respir Crit Care Med 2014; 190:165-74. [PMID: 24940638 DOI: 10.1164/rccm.201311-1986oc] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [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
RATIONALE Cathepsin S (CTSS) activity is increased in bronchoalveolar lavage (BAL) fluid from patients with cystic fibrosis (CF). This activity contributes to lung inflammation via degradation of antimicrobial proteins, such as lactoferrin and members of the β-defensin family. OBJECTIVES In this study, we investigated the hypothesis that airway epithelial cells are a source of CTSS, and mechanisms underlying CTSS expression in the CF lung. METHODS Protease activity was determined using fluorogenic activity assays. Protein and mRNA expression were analyzed by ELISA, Western blotting, and reverse-transcriptase polymerase chain reaction. MEASUREMENTS AND MAIN RESULTS In contrast to neutrophil elastase, CTSS activity was detectable in 100% of CF BAL fluid samples from patients without Pseudomonas aeruginosa infection. In this study, we identified epithelial cells as a source of pulmonary CTSS activity with the demonstration that CF airway epithelial cells express and secrete significantly more CTSS than non-CF control cells in the absence of proinflammatory stimulation. Furthermore, levels of the transcription factor IRF-1 correlated with increased levels of its target gene CTSS. We discovered that miR-31, which is decreased in the CF airways, regulates IRF-1 in CF epithelial cells. Treating CF bronchial epithelial cells with a miR-31 mimic decreased IRF-1 protein levels with concomitant knockdown of CTSS expression and secretion. CONCLUSIONS The miR-31/IRF-1/CTSS pathway may play a functional role in the pathogenesis of CF lung disease and may open up new avenues for exploration in the search for an effective therapeutic target.
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Affiliation(s)
- Sinéad Weldon
- 1 Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, and
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