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Zakkak N, Barclay ME, Swann R, McPhail S, Rubin G, Abel GA, Lyratzopoulos G. The presenting symptom signatures of incident cancer: evidence from the English 2018 National Cancer Diagnosis Audit. Br J Cancer 2024; 130:297-307. [PMID: 38057397 PMCID: PMC10803766 DOI: 10.1038/s41416-023-02507-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Understanding relationships between presenting symptoms and subsequently diagnosed cancers can inform symptom awareness campaigns and investigation strategies. METHODS We used English National Cancer Diagnosis Audit 2018 data for 55,122 newly diagnosed patients, and examined the relative frequency of presenting symptoms by cancer site, and of cancer sites by presenting symptom. RESULTS Among 38 cancer sites (16 cancer groups), three classes were apparent: cancers with a dominant single presenting symptom (e.g. melanoma); cancers with diverse presenting symptoms (e.g. pancreatic); and cancers that are often asymptomatically detected (e.g. chronic lymphocytic leukaemia). Among 83 symptoms (13 symptom groups), two classes were apparent: symptoms chiefly relating to cancers of the same body system (e.g. certain respiratory symptoms mostly relating to respiratory cancers); and symptoms with a diverse cancer site case-mix (e.g. fatigue). The cancer site case-mix of certain symptoms varied by sex. CONCLUSION We detailed associations between presenting symptoms and cancer sites in a large, representative population-based sample of cancer patients. The findings can guide choice of symptoms for inclusion in awareness campaigns, and diagnostic investigation strategies post-presentation when cancer is suspected. They can inform the updating of clinical practice recommendations for specialist referral encompassing a broader range of cancer sites per symptom.
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Affiliation(s)
- N Zakkak
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK.
| | - M E Barclay
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - R Swann
- National Disease Registration Service, NHS England, London, UK
- Cancer Intelligence, Cancer Research UK, London, UK
| | - S McPhail
- National Disease Registration Service, NHS England, London, UK
| | - G Rubin
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - G A Abel
- Medical School, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, London, UK
| | - G Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
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2
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Naidu LR, Rubin G, Benn CA, Govender P. An audit of clinically triaged women at low risk for breast cancer presenting to the Helen Joseph Mammography Unit. S AFR J SURG 2022; 60:182-188. [PMID: 36155373 DOI: 10.17159/2078-5151/sajs3776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND The Helen Joseph Hospital (HJH) breast clinic utilises a clinical triage system to stratify patients based on their risk of breast cancer into high-, medium-, or low-risk profiles. This allows for timeous imaging and subsequent management of those patients at increased risk for breast cancer. The primary objective was to determine the cancer detection rate (CDR). The secondary objective was to correlate biopsy results with the Breast Imaging-Reporting and Data System (BI-RADS) risk assessment. METHODS A retrospective audit of the patients at low risk for breast cancer who were referred to the breast imaging unit (BIU) in 2019 at HJH. Patients were clinically assessed as low risk based on a triage form and were identified using the imaging files stored in the BIU. Results were recorded on Microsoft Excel and calculated as per the American College of Radiology guidelines. RESULTS The total population sample consisted of 398 patients. Two patients were characterised as BI-RADS 4 and underwent breast biopsies. One patient was diagnosed with histologically proven breast cancer. The CDR was 2.51%. The most representative groups were the age group of 60-69 years, BI-RADS breast density B and BI-RADS risk assessment 2. CONCLUSION Amongst the low-risk population, both the CDR and spectrum of disease was comparable to that of a screening population. This may be due to the use of a triage system prior to imaging, as well as an increase in clinical awareness of breast cancer within a tertiary institution.
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Affiliation(s)
- L R Naidu
- Department of Diagnostic Radiology, University of the Witwatersrand, South Africa
| | - G Rubin
- Department of Radiology, Helen Joseph Hospital, University of the Witwatersrand, South Africa
| | - C-A Benn
- Helen Joseph Breast Care Clinic, Helen Joseph Hospital, South Africa
| | - P Govender
- Department of Radiology, Helen Joseph Hospital, University of the Witwatersrand, South Africa
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3
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Riazi A, Aspden T, Rubin G, Ambler G, Jichi F, Mynors-Wallice L, O’Driscoll M, Walters K. Problem-Solving Treatment for People Recently Diagnosed with Visual Impairment: Pilot Randomised Controlled Trial. J Pers Med 2022; 12:jpm12091431. [PMID: 36143215 PMCID: PMC9504279 DOI: 10.3390/jpm12091431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Problem-Solving Treatment (PST) has been used to treat and prevent depression in a variety of settings. However, the impact of PST on improving psychological well-being in those with recent vision loss remains unknown. The aim of this study was to evaluate whether PST may lead to better psychological well-being in people with recent vision loss through a pilot parallel-group randomised controlled trial. Methods: Participants who were diagnosed with visual impairment during the previous 3 months were randomly allocated to either an 8-week PST or treatment as usual (N = 61). Outcome measures were administered at baseline, 3, 6, and 9-months. Results: A linear mixed model demonstrated that PST significantly improved psychological well-being (measured by the Warwick Edinburgh Mental Well-being Scale) (treatment effect = 2.44; 95% CI = 0.40–4.47; p = 0.019). Significant improvements in the PST group for symptoms of distress, quality of life and self-efficacy were also observed. There was no significant difference in mobility. The treatment effect was consistent at all follow-ups. Attrition rate was low (13%). Conclusions: PST was associated with a significant and sustained improvement in a range of outcomes in people with recent vision loss. Further large scale RCT is now required.
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Affiliation(s)
- Afsane Riazi
- Department of Psychology, Richmond American University London, London W4 5AN, UK
- Department of Psychology, Royal Holloway, University of London, Egham TW20 0EX, UK
- Correspondence:
| | - Trefor Aspden
- Department of Psychology, Royal Holloway, University of London, Egham TW20 0EX, UK
| | - Gary Rubin
- Institute of Ophthalmology, University College London, London EC1V 9EL, UK
| | - Gareth Ambler
- Department of Statistical Science, University of London, London WC1E 6BT, UK
| | - Fatima Jichi
- Biostatistics Group, University College London Hospitals/University of London Research Support Centre, University College London, London WC1E 6BT, UK
| | | | - Miriam O’Driscoll
- Department of Psychology, Royal Holloway, University of London, Egham TW20 0EX, UK
| | - Kate Walters
- Department of Primary Care and Population Health, University College London, London NW3 2PF, UK
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4
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Brunetta JM, Baril JG, de Wet JJ, Fraser C, Rubin G, Thomas R, Loemba H, Logue K, Silverman M, Palmart J, Jiang H, Lorgeoux RP, Tossonian H, Kim CJ, Wong A. Cross-sectional comparison of age- and gender-related comorbidities in people living with HIV in Canada. Medicine (Baltimore) 2022; 101:e29850. [PMID: 35839056 DOI: 10.1097/md.0000000000029850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Because antiretroviral therapy (ART) is allowing people living with human immunodeficiency virus (PLWH) to survive longer, they are developing more age-related comorbidities. We evaluated the effects of age and gender on the burden of age-related comorbidities among PLWH. In this retrospective real-world study, de-identified data were extracted from the medical charts of 2000 HIV-positive adults on ART across 10 sites in Canada. The prevalence of age-related comorbidities was determined in 6 age subgroups (<30, 30-39, 40-49, 50-59, 60-69, and ≥70 years). The effects of gender on these comorbidities were also examined. Risks of cardiovascular disease and chronic kidney disease (CKD) were calculated using the Framingham and D:A:D equations. Most persons were White (68%), male (87%), and virologically suppressed (94%). The mean age was 50.3 years (57% aged ≥50 years), and mean CD4+ T-cell count was 616 cells/mm3. The most common comorbidities were neuropsychiatric symptoms (61%), overweight/obesity (43%), liver disease (37%), and dyslipidemia (37%). The mean number of comorbidities increased across age subgroups (P < .001). Across all age subgroups, the prevalence of hypertension (P = .04), dyslipidemia (P = .04), CKD (P = .03), bone fragility (P = .03), and depression (P = .02) differed between males and females. Both age (P < .001) and gender (P < .001) impacted cardiovascular disease and CKD risk. Age and gender influenced the burden, types, and risks of age-related comorbidities in PLWH in this Canadian cohort. These comorbidities should be diagnosed and treated in routine clinical practice.
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Affiliation(s)
| | - Jean-Guy Baril
- Clinique Médecine Urbaine de Quartier Latin, Montreal, Quebec, Canada
| | | | - Chris Fraser
- Cool Aid Community Health Centre, Victoria, British Columbia, Canada
| | - Gary Rubin
- Church Wellesley Health Centre, Toronto, Ontario, Canada
| | - Réjean Thomas
- Clinique médicale l'Actuel, Montreal, Quebec, Canada
| | - Hugues Loemba
- University of Ottawa Health Services, Ottawa, Ontario, Canada
| | - Ken Logue
- St. Clair Medical Associates, Toronto, Ontario, Canada
| | | | - Jean Palmart
- Advisory Physicians Research Services Inc., Victoria, British Columbia, Canada
| | | | | | | | - Connie J Kim
- Gilead Sciences, Inc., Foster City, California, USA
| | - Alexander Wong
- Department of Medicine, University of Saskatchewan, Regina, Saskatchewan, Canada
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5
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Brink HM, Rubin G, Benn CA, Lucas S. An audit of patients clinically deemed as high risk for malignant breast pathology at the Helen Joseph Hospital Breast Clinic. S AFR J SURG 2021; 59:102-107. [PMID: 34515426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND The Helen Joseph Hospital Breast Clinic has implemented a clinical triage system for patients presenting with a variety of breast concerns. The goal of this system is to expedite the process from initial presentation to radiological assessment of patients with suspected breast malignancy or breast abscess in a resource limited setting. The objective was to assess the clinical, imaging and histological diagnoses of breast disease in these patients with malignancy and sepsis. METHODS A retrospective audit of patients clinically deemed high risk for malignant breast pathology referred to the breast imaging unit (BIU) in 2018. Patients were triaged based on strict clinical criteria: presence of a breast mass with or without lymph nodes or a breast abscess. Patients that were subsequently referred for mammography/ultrasound were identified using the patient files in the BIU. Results were recorded on Microsoft Excel and analysed using SAS version 9.2. RESULTS Three hundred and twenty-five patients were included in this study. Eighty-seven (26.8%) were diagnosed with breast cancer and 236 (72.6%) with benign disease. The most common presenting complaint was a palpable mass (n = 227; 69.9%). Ninety-five per cent of patients characterised as BI-RADS 5 had malignant disease. 55.8% of malignancies diagnosed on ultrasound had locally advanced disease. The most common histological diagnosis of malignancy was invasive ductal carcinoma (n = 67, 77%). The most commonly diagnosed benign disease was breast abscess (n = 42, 17.8%). CONCLUSION BI-RADS findings correspond to similar studies, however, a large number of benign breast disease was diagnosed. This may indicate heightened clinical awareness of breast cancer diagnosis and early detection. A significant percentage of malignancies presented as locally advanced. Except for a lower number of invasive lobular carcinoma, the histological spectrum of malignant disease is similar to comparative studies.
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Affiliation(s)
- H-M Brink
- Department of Diagnostic Radiology, University of the Witwatersrand, South Africa
| | - G Rubin
- Department of Radiology, Helen Joseph Hospital, South Africa
| | - C-A Benn
- Breast Surgical Unit, Helen Joseph Hospital, South Africa
| | - S Lucas
- Department of Radiology, Chris Hani Baragwanath Academic Hospital, South Africa
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6
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Christofides NC, Rubin G, Benn CA. An audit of patients presenting with clinically benign breast disease to the Helen Joseph Hospital Breast Imaging Unit. S AFR J SURG 2021; 59:113-117. [PMID: 34515428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Benign breast pathology is a common presenting complaint, and its assessment is important to characterise not to miss malignant pathology. At Helen Joseph Hospital (HJH), patients are triaged at the breast clinic according to the clinical suspicion of benign versus malignant disease. The patients are assigned a colour label based on their clinical presentation. This triage system affects waiting times between clinical examination and mammography appointments. This study aims to assess the association between clinical examination and the radiological and pathological findings of disorders deemed clinically benign, and to ascertain the spectrum of benign breast disorders encountered at HJH. METHOD A retrospective study of imaging results of patients at HJH presenting as clinically benign breast disorders from January to June 2018 was conducted. Assessed Breast Imaging-Reporting and Data System (BI-RADS) score was noted and if core biopsies were performed, their results and patient demographics were documented. RESULTS Of the 1 263 clinically benign patients presenting from January to June 2018, the radiological assessment was: BI-RADS 1: 158 (12.5%), BI-RADS 2: 685 (54.2%), BI-RADS 3: 292 (23.1%), BI-RADS 4a: 54 (4.3%), BI-RADS 4b: 29 (2.3 %), BI-RADS 4c: 21 (1.7%), BI-RADS 5: 24 (1.9%). There were 133 biopsies (including eight BI-RADS 3 patients), with 46 (3.6%) confirmed malignancies. The combined specificity of mammography and ultrasound was 65.52% (54.56-75.39%) and combined sensitivity 91.30% (79.21-97.58%). CONCLUSION There is a vast spectrum of benign conditions presenting in this population group with only 3.6% confirmed malignancies, confirming an accurate triage system utilised at the breast clinic. Radiological imaging is highly sensitive but less specific, emphasising the triad of clinical, radiological and histological assessment as the gold standard with regard to diagnosis of breast disease.
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Affiliation(s)
- N C Christofides
- Department of Diagnostic Radiology, University of the Witwatersrand, South Africa
| | - G Rubin
- Department of Radiology, Helen Joseph Hospital, South Africa
| | - C-A Benn
- Breast Surgical Unit, Helen Joseph Hospital, South Africa
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7
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Brink HM, Rubin G, Benn CA, Lucas S. An audit of patients clinically deemed as high risk for malignant breast pathology at the Helen Joseph Hospital Breast Clinic. S AFR J SURG 2021. [DOI: 10.17159/2078-5151/2021/v59n3a3474] [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: 11/05/2022]
Abstract
ABSTRACT BACKGROUND: The Helen Joseph Hospital Breast Clinic has implemented a clinical triage system for patients presenting with a variety of breast concerns. The goal of this system is to expedite the process from initial presentation to radiological assessment of patients with suspected breast malignancy or breast abscess in a resource limited setting. The objective was to assess the clinical, imaging and histological diagnoses of breast disease in these patients with malignancy and sepsis METHODS: A retrospective audit of patients clinically deemed high risk for malignant breast pathology referred to the breast imaging unit (BIU) in 2018. Patients were triaged based on strict clinical criteria: presence of a breast mass with or without lymph nodes or a breast abscess. Patients that were subsequently referred for mammography/ultrasound were identified using the patient files in the BIU. Results were recorded on Microsoft Excel and analysed using SAS version 9.2 RESULTS: Three hundred and twenty-five patients were included in this study. Eighty-seven (26.8%) were diagnosed with breast cancer and 236 (72.6%) with benign disease. The most common presenting complaint was a palpable mass (n = 227; 69.9%). Ninety-five per cent of patients characterised as BI-RADS 5 had malignant disease. 55.8% of malignancies diagnosed on ultrasound had locally advanced disease. The most common histological diagnosis of malignancy was invasive ductal carcinoma (n = 67, 77%). The most commonly diagnosed benign disease was breast abscess (n = 42, 17.8% CONCLUSION: BI-RADS findings correspond to similar studies, however, a large number of benign breast disease was diagnosed. This may indicate heightened clinical awareness of breast cancer diagnosis and early detection. A significant percentage of malignancies presented as locally advanced. Except for a lower number of invasive lobular carcinoma, the histological spectrum of malignant disease is similar to comparative studies Keywords: malignant breast pathology, high risk patient, Helen Joseph Hospital Breast Clinic
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8
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Christofides NC, Rubin G, Beim CA. An audit of patients presenting with clinically benign breast disease to the Helen Joseph Hospital Breast Imaging Unit. S AFR J SURG 2021. [DOI: 10.17159/2078-5151/2021/v59n3a3477] [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: 11/05/2022]
Abstract
ABSTRACT BACKGROUND: Benign breast pathology is a common presenting complaint, and its assessment is important to characterise not to miss malignant pathology. At Helen Joseph Hospital (HJH), patients are triaged at the breast clinic according to the clinical suspicion of benign versus malignant disease. The patients are assigned a colour label based on their clinical presentation. This triage system affects waiting times between clinical examination and mammography appointments. This study aims to assess the association between clinical examination and the radiological and pathological findings of disorders deemed clinically benign, and to ascertain the spectrum of benign breast disorders encountered at HJH METHOD: A retrospective study of imaging results of patients at HJH presenting as clinically benign breast disorders from January to June 2018 was conducted. Assessed Breast Imaging-Reporting and Data System (BI-RADS) score was noted and if core biopsies were performed, their results and patient demographics were documented RESULTS: Of the 1 263 clinically benign patients presenting from January to June 2018, the radiological assessment was: BI-RADS 1: 158 (12.5%), BI-RADS 2: 685 (54.2%), BI-RADS 3: 292 (23.1%), BI-RADS 4a: 54 (4.3%), BI-RADS 4b: 29 (2.3 %), BI-RADS 4c: 21 (1.7%), BI-RADS 5: 24 (1.9%). There were 133 biopsies (including eight BI-RADS 3 patients), with 46 (3.6%) confirmed malignancies. The combined specificity of mammography and ultrasound was 65.52% (54.56-75.39%) and combined sensitivity 91.30% (79.21-97.58% CONCLUSION: There is a vast spectrum of benign conditions presenting in this population group with only 3.6% confirmed malignancies, confirming an accurate triage system utilised at the breast clinic. Radiological imaging is highly sensitive but less specific, emphasising the triad of clinical, radiological and histological assessment as the gold standard with regard to diagnosis of breast disease Keywords: clinically benign breast disease, breast imaging unit, Helen Joseph Hospital
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Feldman G, Orbach H, Rozen N, Rubin G. Usefulness of prophylactic antibiotics in preventing infection after internal fixation of closed hand fractures. Hand Surg Rehabil 2020; 40:167-170. [PMID: 33309795 DOI: 10.1016/j.hansur.2020.11.002] [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] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
Prophylactic antibiotics (PA) have been shown to be ineffective in reducing the incidence of surgical site infection (SSI) in clean wounds associated with elective surgery of the hand. Routine administration of PA for internal fixation of hand fractures is a subject that has been scarcely studied. We hypothesized that PA do not reduce SSI incidence in fixation of closed hand fractures. We did a retrospective comparative study in patients who underwent open or closed reduction and internal fixation of a hand and carpus fracture. Patient demographics, past medical history, fracture characteristics and the type of internal fixation used were extracted from our electronic archives. Follow-up period lasted for 1 year, during which any form of clinically evident SSI, such as pus formation, wound dehiscence and positive bacterial culture was documented. A total of 107 patients met the inclusion criteria, 63 in the control group and 44 in the test group. The overall infection rate was 6.5%. All infections (3 in the control group and 4 in the test group) were pin-tract infections that resolved completely after pin extraction. Our study did not find significant differences between groups (P = 0.442). No specific fracture pattern was associated with increased total infection rate (p = 0.898). In this study, we found no support for routine administration of PA prior to internal fixation of closed fractures of the hand and carpus. PA should still be administered in selected patients, such as those with decreased immunity or open fractures. Further large-scale research is needed to establish proper guidelines, to reduce the adverse effects of antibiotic treatment.
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Affiliation(s)
- G Feldman
- Orthopedic Department, Emek Medical Center, Yitshak Rabin Boulevard 21, Afula, 1834111, Israel
| | - H Orbach
- Orthopedic Department, Emek Medical Center, Yitshak Rabin Boulevard 21, Afula, 1834111, Israel
| | - N Rozen
- Orthopedic Department, Emek Medical Center, Yitshak Rabin Boulevard 21, Afula, 1834111, Israel; Faculty of Medicine, Technion, Efron St 1, Haifa, Israel
| | - G Rubin
- Orthopedic Department, Emek Medical Center, Yitshak Rabin Boulevard 21, Afula, 1834111, Israel; Faculty of Medicine, Technion, Efron St 1, Haifa, Israel.
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Wright DM, Konstantakopoulou E, Montesano G, Nathwani N, Garg A, Garway-Heath D, Crabb DP, Gazzard G, Adeleke M, Ambler G, Barton K, Bourne R, Broadway D, Bunce C, Buszewicz M, Crabb D, Davis A, Garg A, Garway-Heath D, Gazzard G, Hornan D, Hunter R, Jayaram H, Jiang Y, Konstantakopoulou E, Lim S, Liput J, Manners T, Montesano G, Morris S, Nathwani N, Ometto G, Rubin G, Strouthidis N, Vickerstaff V, Wilson S, Wormald R, Wright D, Zhu H. Visual Field Outcomes from the Multicenter, Randomized Controlled Laser in Glaucoma and Ocular Hypertension Trial (LiGHT). Ophthalmology 2020; 127:1313-1321. [PMID: 32402553 DOI: 10.1016/j.ophtha.2020.03.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To compare visual field outcomes of ocular hypertensive and glaucoma patients treated first with medical therapy with those treated first with selective laser trabeculoplasty (SLT). DESIGN Secondary analysis of patients from the Laser in Glaucoma and Ocular Hypertension study, a multicenter randomized controlled trial. PARTICIPANTS Three hundred forty-four patients (588 eyes) treated first with medical therapy and 344 patients (590 eyes) treated first with SLT. METHODS Visual fields (VFs) were measured using standard automated perimetry and arranged in series (median length and duration, 9 VFs over 48 months). Hierarchical linear models were used to estimate pointwise VF progression rates, which were then averaged to produce a global progression estimate for each eye. Proportions of points and patients in each treatment group with fast (<-1 dB/year) or moderate (<-0.5 dB/year) progression were compared using log-binomial regression. MAIN OUTCOME MEASURES Pointwise and global progression rates of total deviation (TD) and pattern deviation (PD). RESULTS A greater proportion of eyes underwent moderate or fast TD progression in the medical therapy group compared with the SLT group (26.2% vs. 16.9%; risk ratio [RR], 1.55; 95% confidence interval [CI], 1.23-1.93; P < 0.001). A similar pattern was observed for pointwise rates (medical therapy, 26.1% vs. SLT, 19.0%; RR, 1.37; 95% CI, 1.33-1.42; P < 0.001). A greater proportion of pointwise PD rates were categorized as moderate or fast in the medical therapy group (medical therapy, 11.5% vs. SLT, 8.3%; RR, 1.39; 95% CI, 1.32-1.46; P < 0.001). No statistical difference was found in the proportion of eyes that underwent moderate or fast PD progression (medical therapy, 9.9% vs. SLT, 7.1%; RR, 1.39; 95% CI, 0.95, 2.03; P = 0.0928). CONCLUSIONS A slightly larger proportion of ocular hypertensive and glaucoma patients treated first with medical therapy underwent rapid VF progression compared with those treated first with SLT.
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Affiliation(s)
- David M Wright
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom; Health Data Research UK, London, United Kingdom
| | - Evgenia Konstantakopoulou
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; Institute of Ophthalmology, University College London, United Kingdom; Division of Optics and Optometry, University of West Attica, Athens, Greece
| | - Giovanni Montesano
- Optometry and Visual Science, School of Health Science, City, University of London, London, United Kingdom
| | - Neil Nathwani
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - Anurag Garg
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - David Garway-Heath
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; Institute of Ophthalmology, University College London, United Kingdom
| | - David P Crabb
- Optometry and Visual Science, School of Health Science, City, University of London, London, United Kingdom.
| | - Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; Institute of Ophthalmology, University College London, United Kingdom
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11
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Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, Ambler G, Bunce C, Wormald R, Nathwani N, Barton K, Rubin G, Morris S, Buszewicz M. Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT. Health Technol Assess 2020; 23:1-102. [PMID: 31264958 DOI: 10.3310/hta23310] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Newly diagnosed open-angle glaucoma (OAG) and ocular hypertension (OHT) are habitually treated with intraocular pressure (IOP)-lowering eyedrops. Selective laser trabeculoplasty (SLT) is a safe alternative to drops and is rarely used as first-line treatment. OBJECTIVES To compare health-related quality of life (HRQoL) in newly diagnosed, treatment-naive patients with OAG or OHT, treated with two treatment pathways: topical IOP-lowering medication from the outset (Medicine-1st) or primary SLT followed by topical medications as required (Laser-1st). We also compared the clinical effectiveness and cost-effectiveness of the two pathways. DESIGN A 36-month pragmatic, unmasked, multicentre randomised controlled trial. SETTINGS Six collaborating specialist glaucoma clinics across the UK. PARTICIPANTS Newly diagnosed patients with OAG or OHT in one or both eyes who were aged ≥ 18 years and able to provide informed consent and read and understand English. Patients needed to qualify for treatment, be able to perform a reliable visual field (VF) test and have visual acuity of at least 6 out of 36 in the study eye. Patients with VF loss mean deviation worse than -12 dB in the better eye or -15 dB in the worse eye were excluded. Patients were also excluded if they had congenital, early childhood or secondary glaucoma or ocular comorbidities; if they had any previous ocular surgery except phacoemulsification, at least 1 year prior to recruitment or any active treatment for ophthalmic conditions; if they were pregnant; or if they were unable to use topical medical therapy or had contraindications to SLT. INTERVENTIONS SLT according to a predefined protocol compared with IOP-lowering eyedrops, as per national guidelines. MAIN OUTCOME MEASURES The primary outcome was HRQoL at 3 years [as measured using the EuroQol-5 Dimensions, five-level version (EQ-5D-5L) questionnaire]. Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness and safety. RESULTS Of the 718 patients enrolled, 356 were randomised to Laser-1st (initial SLT followed by routine medical treatment) and 362 to Medicine-1st (routine medical treatment only). A total of 652 (91%) patients returned the primary outcome questionnaire at 36 months. The EQ-5D-5L score was not significantly different between the two arms [adjusted mean difference (Laser-1st - Medicine-1st) 0.01, 95% confidence interval (CI) -0.01 to 0.03; p = 0.23] at 36 months. Over 36 months, the proportion of visits at which IOP was within the target range was higher in the Laser-1st arm (93.0%, 95% CI 91.9% to 94.0%) than in the Medicine-1st arm (91.3%, 95% CI 89.9% to 92.5%), with IOP-lowering glaucoma surgery required in 0 and 11 patients, respectively. There was a 97% probability of Laser-1st being more cost-effective than Medicine-1st for the NHS, at a willingness to pay for a quality-adjusted life-year of £20,000, with a reduction in ophthalmology costs of £458 per patient (95% of bootstrap iterations between -£585 and -£345). LIMITATION An unmasked design, although a limitation, was essential to capture any treatment effects on patients' perception. The EQ-5D-5L questionnaire is a generic tool used in multiple settings and may not have been the most sensitive tool to investigate HRQoL. CONCLUSIONS Compared with medication, SLT provided a stable, drop-free IOP control to 74.2% of patients for at least 3 years, with a reduced need for surgery, lower cost and comparable HRQoL. Based on the evidence, SLT seems to be the most cost-effective first-line treatment option for OAG and OHT, also providing better clinical outcomes. FUTURE WORK Longitudinal research into the clinical efficacy of SLT as a first-line treatment will specify the long-term differences of disease progression, treatment intensity and ocular surgery rates between the two pathways. TRIAL REGISTRATION Current Controlled Trials ISRCTN32038223. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 31. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gus Gazzard
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Evgenia Konstantakopoulou
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - David Garway-Heath
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Anurag Garg
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Catey Bunce
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Richard Wormald
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK.,London School of Hygiene & Tropical Medicine, London, UK
| | - Neil Nathwani
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Keith Barton
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Gary Rubin
- Institute of Ophthalmology, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
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12
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Feldman G, Hitti S, Rozen N, Rubin G. Molten metal high pressure injection injury of the hand. Hand Surg Rehabil 2020; 39:328-331. [PMID: 32387689 DOI: 10.1016/j.hansur.2020.03.007] [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] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/13/2020] [Accepted: 03/13/2020] [Indexed: 10/24/2022]
Abstract
The second case of high temperature molten metal, high-pressure injection injury of the hand is reported here. Like in the previous case, there was an innocent-looking entry point with deep thermal injury to the flexor tendons and the digital nerves that appeared a few days after the injury and lead to finger amputation. LEVEL OF EVIDENCE: 5.
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Affiliation(s)
- G Feldman
- Orthopedic Department, HaEmek Medical Center, Yitshak Rabin Boulevard 21, 1834111 Afula, Israel
| | - S Hitti
- Orthopedic Department, HaEmek Medical Center, Yitshak Rabin Boulevard 21, 1834111 Afula, Israel
| | - N Rozen
- Orthopedic Department, HaEmek Medical Center, Yitshak Rabin Boulevard 21, 1834111 Afula, Israel; Faculty of Medicine, Technion, 3200003 Haifa, Israel
| | - G Rubin
- Orthopedic Department, HaEmek Medical Center, Yitshak Rabin Boulevard 21, 1834111 Afula, Israel; Faculty of Medicine, Technion, 3200003 Haifa, Israel.
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13
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Mathew D, Rubin G, Mahomed N, Rayne S. Imaging and clinical features of breast tuberculosis: a review series of 62 cases. Clin Radiol 2020; 75:561.e13-561.e24. [PMID: 32321647 DOI: 10.1016/j.crad.2020.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 03/10/2020] [Indexed: 01/09/2023]
Abstract
AIM To outline the disease burden of breast tuberculosis (TB) as a quantitative analysis amongst three tertiary hospitals in South Africa, with correlation to their clinical, demographic, and imaging features. MATERIALS AND METHODS A retrospective analysis was undertaken over an 18-month period (01/01/2017-30/06/2018) of all patients undergoing laboratory investigations for breast disease at the mammography departments of these three tertiary centres. RESULTS The prevalence of breast TB was 2.5% (n=62) of 2,516 patients. The median age of presentation was 38.5 years (interquartile range [IQR] 33-45). HIV status was known in 45 patients, of whom 36 were HIV infected (80%, 95% CI: 0.65-0.90, p<0.0001). Based on the ultrasound and/or mammogram findings, the patients were classified into five categories: TB breast abscess (40.3%), inflammatory/disseminated (24.2%), isolated TB lymphadenitis (22.6%), nodular (11.3%), and sclerosing form (1.6%). Histology demonstrated necrotising granulomatous inflammation in 57 cases (92%). Acid-fast bacilli (AFB) were positive in 8.1% (n=5) of the cytology and 16.1% (n=10) of the histology specimens. Culture for Mycobacterium tuberculosis was positive in 27% (17 cases), and in 12.9% (n=8). AFB were detected histologically using polymerase chain reaction (PCR) testing. CONCLUSION Knowledge of the varied clinical and radiological features is necessary to maintain a high degree of suspicion to prevent misdiagnoses, inappropriate management, and complications. Ultrasound-guided core biopsy rather than fine-needle aspiration (FNA) is advocated as the first-line intervention in diagnosing or excluding this disease, as it yields a better tissue sample and more often a positive diagnosis.
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Affiliation(s)
- D Mathew
- Department of Diagnostic Radiology, University of the Witwatersrand, Johannesburg, South Africa; Charlotte Maxeke Johannesburg Academic Hospital, Private Bag X39, Johannesburg, 2000, South Africa; Chris Hani Baragwanath Academic Hospital, PO Bertsham, Chris Hani, Johannesburg, 2013, South Africa; Helen Joseph Hospital, Private Bag X47, Auckland Park, 2006, Johannesburg, South Africa.
| | - G Rubin
- Department of Diagnostic Radiology, University of the Witwatersrand, Johannesburg, South Africa; Helen Joseph Hospital, Private Bag X47, Auckland Park, 2006, Johannesburg, South Africa
| | - N Mahomed
- Department of Diagnostic Radiology, University of the Witwatersrand, Johannesburg, South Africa; Department of Diagnostic Radiology, Rahima Moosa Mother and Child Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - S Rayne
- Department of Breast Surgery, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
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14
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Garg A, Vickerstaff V, Nathwani N, Garway-Heath D, Konstantakopoulou E, Ambler G, Bunce C, Wormald R, Barton K, Gazzard G, Adeleke M, Ambler G, Barton K, Bourne R, Broadway D, Bunce C, Buszewicz M, Crabb D, Davis A, Garg A, Garway-Heath D, Gazzard G, Hornan D, Hunter R, Jayaram H, Jiang Y, Konstantakopoulou E, Lim S, Liput J, Manners T, Montesano G, Morris S, Nathwani N, Ometto G, Rubin G, Strouthidis N, Vickerstaff V, Wilson S, Wormald R, Wright D, Zhu H. Efficacy of Repeat Selective Laser Trabeculoplasty in Medication-Naive Open-Angle Glaucoma and Ocular Hypertension during the LiGHT Trial. Ophthalmology 2020; 127:467-476. [PMID: 32005561 DOI: 10.1016/j.ophtha.2019.10.023] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/28/2019] [Accepted: 10/22/2019] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To determine the efficacy of repeat selective laser trabeculoplasty (SLT) in medication-naive open-angle glaucoma (OAG) and ocular hypertensive (OHT) patients requiring repeat treatment for early to medium-term failure during the Laser in Glaucoma and Ocular Hypertension (LiGHT) trial. DESIGN Post hoc analysis of SLT treatment arm of a multicenter prospective randomized controlled trial. PARTICIPANTS Treatment-naive OAG or OHT requiring repeat 360-degree SLT within 18 months. Retreatment was triggered by predefined IOP and disease-progression criteria (using objective individualized target IOPs). METHODS After SLT at baseline, patients were followed for a minimum of 18 months after second (repeat) SLT. A mixed-model analysis was performed with the eye as the unit of analysis, with crossed random effects to adjust for correlation between fellow eyes and repeated measures within eyes. Kaplan-Meier curves plot the duration of effect. MAIN OUTCOME MEASURES Initial (early) IOP lowering at 2 months and duration of effect after initial and repeat SLT. RESULTS A total of 115 eyes of 90 patients received repeat SLT during the first 18 months of the trial. Pretreatment IOP before initial SLT was significantly higher than before retreatment IOP of repeat SLT (mean difference, 3.4 mmHg; 95% confidence interval [CI], 2.6-4.3 mmHg; P < 0.001). Absolute IOP reduction at 2 months was greater after initial SLT compared with repeat SLT (mean difference, 1.0 mmHg; 95% CI, 0.2-1.8 mmHg; P = 0.02). Adjusted absolute IOP reduction at 2 months (adjusting for IOP before initial or repeat laser) was greater after repeat SLT (adjusted mean difference, -1.1 mmHg, 95% CI, -1.7 to -0.5 mmHg; P = 0.001). A total of 34 eyes were early failures (retreatment 2 months after initial SLT) versus 81 later failures (retreatment >2 months after initial SLT). No significant difference in early absolute IOP reduction at 2 months after repeat SLT was noted between early and later failures (mean difference, 0.3 mmHg; 95% CI, -1.1 to 1.8 mmHg; P = 0.655). Repeat SLT maintained drop-free IOP control in 67% of 115 eyes at 18 months, with no clinically relevant adverse events. CONCLUSIONS These exploratory analyses demonstrate that repeat SLT can maintain IOP at or below target IOP in medication-naive OAG and OHT eyes requiring retreatment with at least an equivalent duration of effect to initial laser.
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Affiliation(s)
- Anurag Garg
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, University College London, London, United Kingdom; The Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Neil Nathwani
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - David Garway-Heath
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Evgenia Konstantakopoulou
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - Catey Bunce
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom; School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Wormald
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom; London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Keith Barton
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom.
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15
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Traber GL, Della Volpe-Waizel M, Maloca P, Schmidt-Erfurth U, Rubin G, Roska B, Cordeiro MF, Otto T, Weleber R, Lesmes LA, Arleo A, Scholl HPN. New Technologies for Outcome Measures in Glaucoma: Review by the European Vision Institute Special Interest Focus Group. Ophthalmic Res 2020; 63:88-96. [PMID: 31935739 DOI: 10.1159/000504892] [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: 07/18/2019] [Accepted: 11/19/2019] [Indexed: 11/19/2022]
Abstract
Glaucoma is the leading cause of irreversible blindness worldwide, with an increasing prevalence. The complexity of the disease has been a major challenge in moving the field forward with regard to both pathophysiological insight and treatment. In this context, discussing possible outcome measures in glaucoma trials is of utmost importance and clinical relevance. A recent meeting of the European Vision Institute (EVI) special interest focus group was held on "New Technologies for Outcome Measures in Retina and Glaucoma," addressing both functional and structural outcomes, as well as translational hot topics in glaucoma and retina research. In conjunction with the published literature, this review summarizes the meeting focusing on glaucoma.
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Affiliation(s)
- Ghislaine L Traber
- Department of Ophthalmology, University Hospital Basel, University of Basel, Basel, Switzerland.,Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
| | - Maria Della Volpe-Waizel
- Department of Ophthalmology, University Hospital Basel, University of Basel, Basel, Switzerland.,Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
| | - Peter Maloca
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
| | | | - Gary Rubin
- Institute of Ophthalmology, UCL University College London, London, United Kingdom
| | - Botond Roska
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
| | - M Francesca Cordeiro
- Institute of Ophthalmology, UCL University College London, London, United Kingdom.,Western Eye Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.,Imperial College Ophthalmic Research Group (ICORG), Imperial College London, London, United Kingdom
| | - Tilman Otto
- Heidelberg Engineering GmbH, Heidelberg, Germany
| | - Richard Weleber
- Casey Eye Institute, Departments of Ophthalmology and Molecular and Medical Genetics, University of Oregon Health & Science University, Portland, Oregon, USA
| | | | - Angelo Arleo
- Institut de la Vision, CNRS, INSERM, Sorbonne Université, Paris, France
| | - Hendrik P N Scholl
- Department of Ophthalmology, University Hospital Basel, University of Basel, Basel, Switzerland, .,Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland,
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16
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Tzaridis S, Herrmann P, Charbel Issa P, Degli Esposti S, Wagner SK, Fruttiger M, Egan C, Rubin G, Holz FG, Heeren TFC. Binocular Inhibition of Reading in Macular Telangiectasia Type 2. Invest Ophthalmol Vis Sci 2020; 60:3835-3841. [PMID: 31529080 DOI: 10.1167/iovs.18-26414] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To assess the presence of binocular gain in macular telangiectasia type 2 (MacTel) and its correlation to paracentral scotomas. Methods Sixty-eight patients with MacTel were consecutively recruited for a cross-sectional analysis. Best-corrected visual acuity (BCVA), reading acuity, and reading speed were tested monocularly and binocularly. Macular retinal sensitivity was examined with fundus-controlled perimetry (microperimetry). Scotomas were quantified by their size, their depth, and their proximity to the fovea. Results Binocular reading speed and acuity were lower than monocular reading speed and acuity in the functionally better eye (142 vs. 159 words per minute and 0.43 vs. 0.28 log reading acuity determination, P < 0.001). Magnitude of binocular inhibition of reading speed was correlated to the degree of interocular functional difference (R2 = 0.61, P < 0.001). This correlation was not found for reading acuity or BCVA (R2 < 0.03). Binocular reading speed was negatively correlated to size of right and left eye scotomas, with bigger effect size for left eye scotomas. The magnitude of binocular inhibition was correlated to size of left eye scotomas, but not of right eye scotomas. When both eyes had similar scotoma characteristics, the right eye was more frequently the better reading eye. Conclusions We provide evidence for the presence of binocular inhibition of reading performance in MacTel, likely due to binocular rivalry. This may result from the characteristic paracentral scotomas in noncorresponding retinal fields and, in particular, a disruptive projection of scotomas in reading direction arising from the left eyes. Patients may benefit from occluding one eye while reading.
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Affiliation(s)
- Simone Tzaridis
- University of Bonn, Department of Ophthalmology, Bonn, Germany
| | | | - Peter Charbel Issa
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, and Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Simona Degli Esposti
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom.,NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Siegfried K Wagner
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom.,NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom.,University College London Institute of Ophthalmology, London, United Kingdom
| | - Marcus Fruttiger
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom.,University College London Institute of Ophthalmology, London, United Kingdom
| | - Catherine Egan
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom.,NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom.,University College London Institute of Ophthalmology, London, United Kingdom
| | - Gary Rubin
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Frank G Holz
- University of Bonn, Department of Ophthalmology, Bonn, Germany
| | - Tjebo F C Heeren
- University of Bonn, Department of Ophthalmology, Bonn, Germany.,Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom.,University College London Institute of Ophthalmology, London, United Kingdom
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17
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Feldman G, Rozen N, Eliyahu AC, Epshtein A, Saleem-Zedan R, Rubin G. High-pressure injection injuries of the fingers: Long-term follow-up in patients after extensive debridement. Hand Surg Rehabil 2019; 38:312-316. [PMID: 31400497 DOI: 10.1016/j.hansur.2019.07.010] [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] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/12/2019] [Accepted: 07/30/2019] [Indexed: 11/18/2022]
Abstract
High-pressure injection injuries to the fingers resulting from the introduction of a foreign substance, such as oil or paint, through a minor puncture wound are rare but can have serious clinical consequences. The objective of this article was to examine the long-term outcomes after surgical debridement of these injuries. We present a retrospective case series of 8 adults who had a high-pressure injection injury to their hand and underwent surgical debridement in our facility. Data were extracted from our outpatient registry. Assessment included a full physical examination, grip strength, range of motion, two-point discrimination and Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. We followed 8 male patients for an average of 12.7 years. Their average age was 37 at time of injury and all had injured their right dominant hand. Seventy-five percent of the injuries were to the index finger. Seven out of the 8 patients returned to their pre-injury occupation, 4 out of 8 patients had reduced range of motion of the affected digit. Injury sequelae adversely affected activities of daily living (ADL) with an average QuickDASH score of 26. Grip strength in the injured hand was reduced by an average of 35% in 6 out of 8 patients compared with the uninjured hand. Sensation was also reduced in the affected digit in 7 out of 8 patients. All patients suffered from some level of neuropathic pain and/or cold intolerance. High pressure injection injury to the fingers is a serious event found amongst industrial laborers. In most patients, this injury will lead to long-term disability along with a negative impact on ADL. However, most patients eventually return to their pre-injury occupation. Extensive, single or repeat debridement of high-pressure injection injuries remains a valid treatment option with good long-term results.
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Affiliation(s)
- G Feldman
- Orthopedic Department, Emek Medical Center, Yitshak-Rabin boulevard 21, Afula, 1834111, Israel.
| | - N Rozen
- Orthopedic Department, Emek Medical Center, Yitshak-Rabin boulevard 21, Afula, 1834111, Israel; Faculty of Medicine, Technion, Efron St 1, Bat Galim P.O.B. 9649, Haifa, 31096, Israel
| | - A C Eliyahu
- Orthopedic Department, Emek Medical Center, Yitshak-Rabin boulevard 21, Afula, 1834111, Israel
| | - A Epshtein
- Orthopedic Department, Emek Medical Center, Yitshak-Rabin boulevard 21, Afula, 1834111, Israel
| | - R Saleem-Zedan
- Orthopedic Department, Emek Medical Center, Yitshak-Rabin boulevard 21, Afula, 1834111, Israel
| | - G Rubin
- Orthopedic Department, Emek Medical Center, Yitshak-Rabin boulevard 21, Afula, 1834111, Israel; Faculty of Medicine, Technion, Efron St 1, Bat Galim P.O.B. 9649, Haifa, 31096, Israel
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18
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Della Volpe-Waizel M, Traber GL, Maloca P, Zinkernagel M, Schmidt-Erfurth U, Rubin G, Roska B, Otto T, Weleber RG, Scholl HPN. New Technologies for Outcome Measures in Retinal Disease: Review from the European Vision Institute Special Interest Focus Group. Ophthalmic Res 2019; 63:77-87. [PMID: 31352462 DOI: 10.1159/000501887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/03/2019] [Indexed: 01/03/2023]
Abstract
Novel diagnostic tools to measure retinal function and structure are rapidly being developed and introduced into clinical use. Opportunities exist to use these informative and robust measures as endpoints for clinical trials to determine efficacy and to monitor safety of therapeutic interventions. In order to inform researchers and clinician-scientists about these new diagnostic tools, a workshop was organized by the European Vision Institute. Invited speakers highlighted the recent advances in state-of-the-art technologies for outcome measures in the field of retina. This review highlights the workshop's presentations in the context of published literature.
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Affiliation(s)
- Maria Della Volpe-Waizel
- Department of Ophthalmology, University of Basel, Basel, Switzerland.,Institute of Molecular and Clinical Ophthalmology (IOB), Basel, Switzerland
| | - Ghislaine L Traber
- Department of Ophthalmology, University of Basel, Basel, Switzerland.,Institute of Molecular and Clinical Ophthalmology (IOB), Basel, Switzerland
| | - Peter Maloca
- Institute of Molecular and Clinical Ophthalmology (IOB), Basel, Switzerland
| | - Martin Zinkernagel
- Department of Ophthalmology and Department of Clinical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Gary Rubin
- UCL University College London, Institute of Ophthalmology, London, United Kingdom
| | - Botond Roska
- Institute of Molecular and Clinical Ophthalmology (IOB), Basel, Switzerland
| | - Tilman Otto
- Heidelberg Engineering GmbH, Heidelberg, Germany
| | - Richard G Weleber
- Casey Eye Institute, Departments of Ophthalmology and Molecular and Medical Genetics, University of Oregon Health and Science University, Portland, Oregon, USA
| | - Hendrik P N Scholl
- Department of Ophthalmology, University of Basel, Basel, Switzerland, .,Institute of Molecular and Clinical Ophthalmology (IOB), Basel, Switzerland,
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Marques AP, Macedo AF, Lima Ramos P, Moreno LH, Butt T, Rubin G, Santana R. Productivity Losses and Their Explanatory Factors Amongst People with Impaired Vision. Ophthalmic Epidemiol 2019; 26:378-392. [PMID: 31280630 DOI: 10.1080/09286586.2019.1632904] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: To estimate productivity losses amongst people with impaired vision in Portugal and to investigate explanatory factors associated with non-participation in the labour market.Methods: A total of 546 visually impaired individuals participated in face-to-face interviews. Participants were asked about their workforce participation to determine productivity (employment status questionnaire), their health-related quality of life - HRQoL (EQ-5D) and their visual acuity and visual ability (Activity Inventory). Productivity losses included absenteeism and reduction in workforce participation. Logistic regression was used to determine independent factors associated with participation in the labour market.Results: From the 546 participants, 50% were retired, 47% were of working age and 3% were students. The employment rate was 28%, and the unemployment rate was 21% for the working age sample. For those of working age, productivity losses were estimated at €1.51 million per year, mean of €5496 per participant. The largest contributor to productivity losses was reduced workforce participation, estimated from 159 early retired or unemployed participants. After controlling for visual acuity and ability, younger individuals, with more years of education, without comorbidities and high HRQoL had a higher probability of being employed.Conclusions: Our findings show a high unemployment rate and high productivity losses amongst people with impaired vision. The probability of being employed was associated with education, HRQoL and comorbidities. We speculate that promoting education and health through effective visual rehabilitation programs may help to increase participation in the labour market. These findings can inform decisions to intervene to reduce the burden of vision loss.
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Affiliation(s)
- Ana Patricia Marques
- National School of Public Health, NOVA University of Lisbon, Lisbon, Portugal.,Public Health Research Center, National School of Public Health, NOVA University of Lisbon, Lisbon, Portugal
| | - Antonio Filipe Macedo
- Department of Medicine, Optometry Linnaeus University Kalmar, Kalmar, Sweden.,Low Vision and Visual Rehabilitation Lab, Department and Center of Physics-Optometry and Vision Science, University of Minho Braga, Braga, Portugal
| | - Pedro Lima Ramos
- Department of Medicine, Optometry Linnaeus University Kalmar, Kalmar, Sweden.,Low Vision and Visual Rehabilitation Lab, Department and Center of Physics-Optometry and Vision Science, University of Minho Braga, Braga, Portugal
| | - Laura Hernandez Moreno
- Low Vision and Visual Rehabilitation Lab, Department and Center of Physics-Optometry and Vision Science, University of Minho Braga, Braga, Portugal
| | - Thomas Butt
- National School of Development, Peking University, Beijing, China.,Institute of Ophthalmology, University College London, London, UK
| | - Gary Rubin
- Institute of Ophthalmology, University College London, London, UK
| | - Rui Santana
- National School of Public Health, NOVA University of Lisbon, Lisbon, Portugal.,Public Health Research Center, National School of Public Health, NOVA University of Lisbon, Lisbon, Portugal
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20
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Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, Ambler G, Bunce C, Wormald R, Nathwani N, Barton K, Rubin G, Buszewicz M. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet 2019; 393:1505-1516. [PMID: 30862377 PMCID: PMC6495367 DOI: 10.1016/s0140-6736(18)32213-x] [Citation(s) in RCA: 286] [Impact Index Per Article: 57.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 08/28/2018] [Accepted: 09/04/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Primary open angle glaucoma and ocular hypertension are habitually treated with eye drops that lower intraocular pressure. Selective laser trabeculoplasty is a safe alternative but is rarely used as first-line treatment. We compared the two. METHODS In this observer-masked, randomised controlled trial treatment-naive patients with open angle glaucoma or ocular hypertension and no ocular comorbidities were recruited between 2012 and 2014 at six UK hospitals. They were randomly allocated (web-based randomisation) to initial selective laser trabeculoplasty or to eye drops. An objective target intraocular pressure was set according to glaucoma severity. The primary outcome was health-related quality of life (HRQoL) at 3 years (assessed by EQ-5D). Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness, and safety. Analysis was by intention to treat. This study is registered at controlled-trials.com (ISRCTN32038223). FINDINGS Of 718 patients enrolled, 356 were randomised to the selective laser trabeculoplasty and 362 to the eye drops group. 652 (91%) returned the primary outcome questionnaire at 36 months. Average EQ-5D score was 0·89 (SD 0·18) in the selective laser trabeculoplasty group versus 0·90 (SD 0·16) in the eye drops group, with no significant difference (difference 0·01, 95% CI -0·01 to 0·03; p=0·23). At 36 months, 74·2% (95% CI 69·3-78·6) of patients in the selective laser trabeculoplasty group required no drops to maintain intraocular pressure at target. Eyes of patients in the selective laser trabeculoplasty group were within target intracoluar pressure at more visits (93·0%) than in the eye drops group (91·3%), with glaucoma surgery to lower intraocular pressure required in none versus 11 patients. Over 36 months, from an ophthalmology cost perspective, there was a 97% probability of selective laser trabeculoplasty as first treatment being more cost-effective than eye drops first at a willingness to pay of £20 000 per quality-adjusted life-year gained. INTERPRETATION Selective laser trabeculoplasty should be offered as a first-line treatment for open angle glaucoma and ocular hypertension, supporting a change in clinical practice. FUNDING National Institute for Health Research, Health and Technology Assessment Programme.
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Affiliation(s)
- Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK.
| | - Evgenia Konstantakopoulou
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK
| | - David Garway-Heath
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK
| | - Anurag Garg
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, University College London, London, UK; The Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rachael Hunter
- The Research Department of Primary Care and Population Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Catey Bunce
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Richard Wormald
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK; London School of Hygiene & Tropical Medicine, London, UK
| | - Neil Nathwani
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Keith Barton
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK
| | - Gary Rubin
- Institute of Ophthalmology, University College London, London, UK
| | - Marta Buszewicz
- The Research Department of Primary Care and Population Health, University College London, London, UK
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21
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Das A, Quartilho A, Xing W, Bunce C, Rubin G, MacKenzie K, Adams G, Dahlmann-Noor A, Theodorou M. Visual functioning in adults with Idiopathic Infantile Nystagmus Syndrome (IINS). Strabismus 2018; 26:203-209. [PMID: 30325248 DOI: 10.1080/09273972.2018.1526958] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE IINS is associated with mild/moderate visual impairment, strabismus and compensatory head postures (CHP), which can negatively impact quality of life. Standard visual acuity assessments tend to underestimate the effect of IINS on visual functioning. Published evidence on the effect of INS on quality of life is slowly emerging. Our study examines visual functioning of adults with IINS using the National Eye Institute Visual Function Questionairre-25 (VFQ-25). METHODS 38 participants were recruited to participate in the study. All participants underwent detailed clinical examination, as well as appropriate investigations and were asked to complete the self administered VFQ-25. RESULTS 35/38 participants completed the questionnaire. The mean age of the population was 35.1 years (range 17-64). Mean overall VFQ-25 score at baseline was 65 (SD 13, range 34-91). Participants specifically demonstrated lowest scores for the impact of IINS on mental health, role limitations and dependency. 26/35 of participants were not driving, either due to sub-normal vision, lack of confidence or difficulties with contrast sensitivity. CONCLUSIONS IINS can have a greater than expected impact on an individual's quality of life, without necessarily causing markedly reduced visual acuity. Our study showed lowest scores in the domains of mental health and wellbeing. Patients also reported reduced visual functioning in driving, which can impact adversely on employability and independence. Visual functioning questionnaires such as the VFQ-25 may provide more functional information on the impact of nystagmus on an individual's quality of life than objective measures such as high contrast Snellen and/or LogMAR visual acuity.
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Affiliation(s)
- Aditi Das
- a Paediatric Ophthalmology and Strabismus , Moorfields Eye Hospital , London
| | - Ana Quartilho
- b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London.,c UCL Institute of Ophthalmology , University College London
| | - Wen Xing
- b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London
| | - Catey Bunce
- b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London.,d Kings College , University of London.,e London School of Hygiene & Tropical Medicine, University of London , London
| | - Gary Rubin
- b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London.,c UCL Institute of Ophthalmology , University College London
| | - Kelly MacKenzie
- a Paediatric Ophthalmology and Strabismus , Moorfields Eye Hospital , London
| | - Gillian Adams
- a Paediatric Ophthalmology and Strabismus , Moorfields Eye Hospital , London
| | - Annegret Dahlmann-Noor
- a Paediatric Ophthalmology and Strabismus , Moorfields Eye Hospital , London.,b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London
| | - Maria Theodorou
- a Paediatric Ophthalmology and Strabismus , Moorfields Eye Hospital , London.,b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London
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22
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Rubin G, Sanchez J, Bayne J, Takayama H, Takeda K, Naka Y, Garan H, Farr M, Wan. E. Clinical Outcomes After Tricuspid Annuloplasty Prior to Cardiac Transplantation: A Single Center Experience. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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23
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Dobson C, Russell A, Brown S, Rubin G. The role of social context in symptom appraisal and help-seeking among people with lung or colorectal symptoms: A qualitative interview study. Eur J Cancer Care (Engl) 2018; 27:e12815. [PMID: 29419943 DOI: 10.1111/ecc.12815] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2017] [Indexed: 12/01/2022]
Abstract
Prolonged diagnostic intervals are associated with poorer outcomes, and the patient interval appears to be a substantial contributor to the overall length of the diagnostic interval. This study sought to understand how the broader context of people's lives influenced symptom appraisal and help-seeking, comparing experiences by length of the patient interval. Patients referred with a suspicion of lung or colorectal cancer were invited to complete a questionnaire about their symptoms, with 26 respondents purposively sampled to take part in a semi-structured interview about their patient intervals. Embodied experience, appraisal, help-seeking decision-making and consultation were identified as component stages of the patient interval, with the factors affecting movement between these stages located in one of four contextual domains: individual experience, interpersonal relationships, healthcare system interactions and social and temporal context. The length of the patient interval was related to the type of symptom(s) experienced, discussion of symptoms with others and the social responsibilities people held during symptomatic periods. A contextual model of the patient interval illustrates the stages and domains of this interval, as grounded in the data from this study. The model has potential application to future studies examining the patient interval for a range of symptoms.
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Affiliation(s)
- C Dobson
- Institute of Health and Society, Sir James Spence Institute, Newcastle University, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - A Russell
- Department of Anthropology, Durham University, Durham, Uk
| | - S Brown
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, UK
| | - G Rubin
- Institute of Health and Society, Sir James Spence Institute, Newcastle University, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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24
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Theodorou M, Quartilho A, Xing W, Bunce C, Rubin G, Adams G, Dahlmann-Noor A. Soft Contact Lenses to Optimize Vision in Adults with Idiopathic Infantile Nystagmus: A Pilot Parallel Randomized Controlled Trial. Strabismus 2018; 26:11-21. [PMID: 29333910 DOI: 10.1080/09273972.2017.1418394] [Citation(s) in RCA: 7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The optimal management of infantile nystagmus syndrome (INS) is still unclear. Contact lenses (CL) may be superior to glasses in improving visual function in INS but it is not known whether their beneficial effects are due to optical correction alone, or to an additional proprioceptive effect, and whether soft CLs would be as effective as rigid CLs. There is little data on feasibility and and the present study aimed to provide this information. METHODS We completed a pilot Randomized Control Trial (RCT) at a single tertiary referral centre in London, UK. We enrolled 38 adults with idiopathic INS and randomised them to either plano CL (with corrective spectacles if required) or to corrective CL. CL wear was required for a minimum of 2 weeks. Primary outcome measures were feasibility and safety of CL wear in INS; secondary outcome measures were visual acuity and nystagmus waveform parameters. RESULTS 27 completed the study (27/38,71%). 4 partcipants withdrew due to difficulty with CL insertion/removal and 7 were lost to follow up. CL tolerability was high (24/27,89%) - 2 found the CLs irritant, and 1 had an exacerbation of allergic eye disease. At two weeks, mean improvement in binocular visual acuity from baseline with plano CLs was 0.07 logMAR (95% confidence interval (CI: 0.03-0.11) and 0.06 logMAR with fully corrective CLs (95% CI:0.02-0.1). Mean improvement in the eXpanded Nystagmus Acuity Function (NAFX, a nystagmus acuity function based on eye movement recording) with plano CLs was -0.04(95% CI: -0.08-0.005) and -0.05 with fully corrective CLs(95% CI: -0.09-0.003). CONCLUSIONS CLs are well tolerated, with a low risk profile. Whilst our study was not powered to detect significant changes in BCVA and waveform parameters between treatment arms, we observed a trend towards an improvement in visual function at two weeks from baseline with CLs.
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Affiliation(s)
- Maria Theodorou
- a Paediatric Ophthalmology and Strabismus , Moorfields Eye Hospital , London , UK.,b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London , UK
| | - Ana Quartilho
- b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London , UK.,c UCL Institute of Ophthalmology , University College London , London , UK
| | - Wen Xing
- b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London , UK
| | - Catey Bunce
- b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London , UK.,d Kings College, University of London , London , UK.,e Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine , London , UK
| | - Gary Rubin
- b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London , UK.,c UCL Institute of Ophthalmology , University College London , London , UK
| | - Gillian Adams
- a Paediatric Ophthalmology and Strabismus , Moorfields Eye Hospital , London , UK
| | - Annegret Dahlmann-Noor
- a Paediatric Ophthalmology and Strabismus , Moorfields Eye Hospital , London , UK.,b National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital , London , UK
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25
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Krieger Y, Rubin G, Schulz A, Rosenberg N, Levi A, Singer A, Rosenberg L, Shoham Y. Bromelain-based enzymatic debridement and minimal invasive modality (mim) care of deeply burned hands. Ann Burns Fire Disasters 2017; 30:198-204. [PMID: 29849523 PMCID: PMC5946757] [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] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 08/05/2017] [Indexed: 06/08/2023]
Abstract
The objective was to critically review the data and assess the implications of NexoBrid [NexoBrid-NXB formerly Debrase Gel Dressing-DGD]a in the special field of deep hand burns. Detailed analysis of endpoints in the treatment of hand burn patients was conducted as part of a multi-center, open label, randomized, controlled two-arm study to evaluate the safety and efficacy of NXB enzymatic debridement, comparing it to the current standard of care (SOC). These results were compared to a large cohort of patients treated with NXB in a previous, single arm study. Thirty-one burned hands were treated with NXB and 41 hand burns were in the SOC group. In the NXB group, 4 out of 31 hand burns (12.9%) required some excisional debridement compared to 29 out of the 41 (70.7%) in the SOC group (p<0.0001). Mean percentage of burn wound area excised in the NXB group was 4.4 ± 13.1% compared to 52.0 ± 41.4% in the SOC group (p<0.0001). None of the NXB-treated hands required escharotomy compared to 4 out of the 41 (9.7%) in the SOC group. NXB enzymatic debridement demonstrated a statistically significant reduction in burn wound excision and auto-grafting compared to SOC, and seems to prevent the need for emergency escharotomy. a DGD is produced by MediWound and distributed under the name NexoBrid®.
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Affiliation(s)
- Y. Krieger
- Department of Plastic Surgery and Burn Unit, Soroka Medical Center, The Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - G. Rubin
- Orthopedic Department, Emek Medical Center, Afula / Faculty of Medicine, Technion, Haifa, Israel
| | - A. Schulz
- Klinik für Plastische Chirurgie, Handchirurgie - Schwerbrandverletztenzentrum - Krankenhaus Merheim, Lehrstuhl für Plastische Chirurgie der Universität Witten/Herdecke, Köln, Germany
| | - N. Rosenberg
- Cleft Lip & Palate & Craniofacial Deformities Unite, Department of Plastic Surgery, Meir Hospital Kfar Saba, Israel / MediWound Ltd. Israel
| | - A. Levi
- Cleft Lip & Palate & Craniofacial Deformities Unite, Department of Plastic Surgery, Meir Hospital Kfar Saba, Israel / MediWound Ltd. Israel
| | - A.J. Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
| | - L. Rosenberg
- Department of Plastic Surgery and Burn Unit, Soroka Medical Center, The Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Y. Shoham
- Department of Plastic Surgery and Burn Unit, Soroka Medical Center, The Ben-Gurion University of the Negev, Beer Sheva, Israel
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26
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Gazzard G, Konstantakopoulou E, Garway-Heath D, Barton K, Wormald R, Morris S, Hunter R, Rubin G, Buszewicz M, Ambler G, Bunce C. Laser in Glaucoma and Ocular Hypertension (LiGHT) trial. A multicentre, randomised controlled trial: design and methodology. Br J Ophthalmol 2017; 102:593-598. [PMID: 28903966 DOI: 10.1136/bjophthalmol-2017-310877] [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] [Received: 06/13/2017] [Revised: 07/30/2017] [Accepted: 08/05/2017] [Indexed: 11/03/2022]
Abstract
PURPOSE The Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial aims to establish whether initial treatment with selective laser trabeculoplasty (SLT) is superior to initial treatment with topical medication for primary open-angle glaucoma (POAG) or ocular hypertension (OHT). DESIGN The LiGHT Trial is a prospective, unmasked, multicentre, pragmatic, randomised controlled trial. 718 previously untreated patients with POAG or OHT were recruited at six collaborating centres in the UK between 2012 and 2014. The trial comprises two treatment arms: initial SLT followed by conventional medical therapy as required, and medical therapy without laser therapy. Randomisation was provided online by a web-based randomisation service. Participants will be monitored for 3 years, according to routine clinical practice. The target intraocular pressure (IOP) was set at baseline according to an algorithm, based on disease severity and lifetime risk of loss of vision at recruitment, and subsequently adjusted on the basis of IOP control, optic disc and visual field. The primary outcome measure is health-related quality of life (HRQL) (EQ-5D five-level). Secondary outcomes are treatment pathway cost and cost-effectiveness, Glaucoma Utility Index, Glaucoma Symptom Scale, Glaucoma Quality of Life, objective measures of pathway effectiveness, visual function and safety profiles and concordance. A single main analysis will be performed at the end of the trial on an intention-to-treat basis. CONCLUSIONS The LiGHT Trial is a multicentre, pragmatic, randomised clinical trial that will provide valuable data on the relative HRQL, clinical effectiveness and cost-effectiveness of SLT and topical IOP-lowering medication. TRIAL REGISTRATION NUMBER ISRCTN32038223, Pre-results.
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Affiliation(s)
- Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College, London, UK
| | - Evgenia Konstantakopoulou
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College, London, UK.,Centre for Public Health Research, School of Health Sciences, City University, London, UK
| | - David Garway-Heath
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College, London, UK
| | - Keith Barton
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK
| | - Richard Wormald
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College, London, UK
| | - Stephen Morris
- Department of Applied Health Research, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Rachael Hunter
- Priment Clinical Trials Unit, University College London, Royal Free Medical School, London, UK
| | - Gary Rubin
- Institute of Ophthalmology, University College, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College Medical School, London, UK
| | - Gareth Ambler
- Department of Statistical Science, Faculty of Mathematics and Physical Sciences, University College London, London, UK
| | - Catey Bunce
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK.,International Centre for Eye Health (ICEH), Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK.,Department of Primary Care and Public Health, King's College London, London, UK
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Tørring ML, Murchie P, Hamilton W, Vedsted P, Esteva M, Lautrup M, Winget M, Rubin G. Evidence of advanced stage colorectal cancer with longer diagnostic intervals: a pooled analysis of seven primary care cohorts comprising 11 720 patients in five countries. Br J Cancer 2017; 117:888-897. [PMID: 28787432 PMCID: PMC5589987 DOI: 10.1038/bjc.2017.236] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/24/2017] [Accepted: 06/29/2017] [Indexed: 12/15/2022] Open
Abstract
Background: The benefits from expedited diagnosis of symptomatic cancer are uncertain. We aimed to analyse the relationship between stage of colorectal cancer (CRC) and the primary and specialist care components of the diagnostic interval. Methods: We identified seven independent data sets from population-based studies in Scotland, England, Canada, Denmark and Spain during 1997–2010 with a total of 11 720 newly diagnosed CRC patients, who had initially presented with symptoms to a primary care physician. Data were extracted from patient records, registries, audits and questionnaires, respectively. Data sets were required to hold information on dates in the diagnostic interval (defined as the time from the first presentation of symptoms in primary care until the date of diagnosis), symptoms at first presentation in primary care, route of referral, gender, age and histologically confirmed stage. We carried out reanalysis of all individual data sets and, using the same method, analysed a pooled individual patient data set. Results: The association between intervals and stage was similar in the individual and combined data set. There was a statistically significant convex (∩-shaped) association between primary care interval and diagnosis of advanced (i.e., distant or regional) rather than localised CRC (P=0.004), with odds beginning to increase from the first day on and peaking at 90 days. For specialist care, we saw an opposite and statistically significant concave (∪-shaped) association, with a trough at 60 days, between the interval and diagnosis of advanced CRC (P<0.001). Conclusions: This study provides evidence that longer diagnostic intervals are associated with more advanced CRC. Furthermore, the study cannot define a specific ‘safe’ waiting time as the length of the primary care interval appears to have negative impact from day one.
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Affiliation(s)
- M L Tørring
- Department of Anthropology, School of Culture and Society, Aarhus University, Moesgaard Allé 20, Højbjerg DK-8270, Denmark
| | - P Murchie
- Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - W Hamilton
- University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter EX1 2 LU, UK
| | - P Vedsted
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Bartholins Allé 20, Aarhus C DK-8000, Denmark
| | - M Esteva
- Primary Care Research Unit, Primary Care Majorca Department, Balearic Islands Health Research Institute (IdISBa), Reina Esclaramunda 9, Palma Mallorca 07003, Spain
| | - M Lautrup
- Department of Organ and Plastic Surgery, Breast Centre, Vejle Hospital, Kabbeltoft 25, Vejle DK-7100, Denmark
| | - M Winget
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, MSOB #X214, Stanford, California CA 94305, USA
| | - G Rubin
- School of Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University, Queen's Campus, University Boulevard, Stockton on Tees, England TS17 6BH, UK
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Aboshiha J, Kumaran N, Kalitzeos A, Hogg C, Rubin G, Michaelides M. A Quantitative and Qualitative Exploration of Photoaversion in Achromatopsia. Invest Ophthalmol Vis Sci 2017; 58:3537-3546. [PMID: 28715587 PMCID: PMC5510991 DOI: 10.1167/iovs.17-21935] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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] [Indexed: 11/24/2022] Open
Abstract
Purpose Photoaversion (PA) is a disabling and ubiquitous feature of achromatopsia (ACHM). We aimed to help define the characteristics of this important symptom, and present the first published assessment of its impact on patients' lives, as well as quantitative and qualitative PA assessments. Methods Molecularly confirmed ACHM subjects were assessed for PA using four tasks: structured survey of patient experience, novel quantitative subjective measurement of PA, visual acuities in differing ambient lighting, and objective palpebral aperture-related PA testing. Results Photoaversion in ACHM was found to be the most significant symptom for a substantial proportion (38%) of patients. A novel subjective PA measurement technique was developed and demonstrated fidelity with more invasive paradigms without exposing often very photosensitive patients to brighter light intensities used elsewhere. An objective PA measurement was also refined for use in trials, indicating that higher light intensities than previously published are likely to be needed. Monocular testing, as required for trials, was also validated for the first time. Conclusions This study offers new insights into PA in ACHM. It provides the first structured evidence of the great significance of this symptom to patients, suggesting that PA should be considered as an additional outcome measure in therapeutic trials. It also offers new insights into the characteristics of PA in ACHM, and describes both subjective and objective measures of PA that could be employed in clinical trials.
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Affiliation(s)
- Jonathan Aboshiha
- UCL Institute of Ophthalmology, University College London, London, United Kingdom 2Moorfields Eye Hospital, London, United Kingdom
| | - Neruban Kumaran
- UCL Institute of Ophthalmology, University College London, London, United Kingdom 2Moorfields Eye Hospital, London, United Kingdom
| | - Angelos Kalitzeos
- UCL Institute of Ophthalmology, University College London, London, United Kingdom 2Moorfields Eye Hospital, London, United Kingdom
| | - Chris Hogg
- Moorfields Eye Hospital, London, United Kingdom
| | - Gary Rubin
- UCL Institute of Ophthalmology, University College London, London, United Kingdom
| | - Michel Michaelides
- UCL Institute of Ophthalmology, University College London, London, United Kingdom 2Moorfields Eye Hospital, London, United Kingdom
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Abstract
Health state utility values are a major source of uncertainty in economic evaluations of interventions for age-related macular degeneration (AMD). This review identifies and critiques published utility values and methods for eliciting de novo utility values in AMD. We describe how utility values have been used in healthcare decision making and provide guidance on the choice of utility values for future economic evaluations for AMD. Literature was searched using PubMed, and health technology assessments (HTA) were searched using HTA agency websites to identify articles reporting utility values or approaches to derive utility values in AMD and articles applying utilities for use in healthcare decision making relating to treatments for AMD. A total of 70 studies qualified for data extraction, 22 of which were classified as containing utility values and/or elicitation methods, and 48 were classified as using utility values in decision making. A large number of studies have elicited utility values for AMD, although those applied to decision making have focused on a few of these. There is an appreciation of the challenges in the measurement and valuation of health states, with recent studies addressing challenges such as the insensitivity of generic health-related quality of life (HRQoL) questionnaires and utility in the worse-seeing eye. We would encourage careful consideration when choosing utility values in decision making and an explicit critique of their applicability to the decision problem.
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Affiliation(s)
- Thomas Butt
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK.
| | - Adnan Tufail
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
- Moorfields Eye Hospital, London, UK
| | - Gary Rubin
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
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Hall N, Birt L, Rees CJ, Walter FM, Elliot S, Ritchie M, Weller D, Rubin G. Concerns, perceived need and competing priorities: a qualitative exploration of decision-making and non-participation in a population-based flexible sigmoidoscopy screening programme to prevent colorectal cancer. BMJ Open 2016; 6:e012304. [PMID: 27836872 PMCID: PMC5129085 DOI: 10.1136/bmjopen-2016-012304] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Optimising uptake of colorectal cancer (CRC) screening is important to achieve projected health outcomes. Population-based screening by flexible sigmoidoscopy (FS) was introduced in England in 2013 (NHS Bowel scope screening). Little is known about reactions to the invitation to participate in FS screening, as offered within the context of the Bowel scope programme. We aimed to investigate responses to the screening invitation to inform understanding of decision-making, particularly in relation to non-participation in screening. DESIGN Qualitative analysis of semistructured in-depth interviews and written accounts. PARTICIPANTS AND SETTING People from 31 general practices in the North East and East of England invited to attend FS screening as part of NHS Bowel scope screening programme were sent invitations to take part in the study. We purposively sampled interviewees to ensure a range of accounts in terms of beliefs, screening attendance, sex and geographical location. RESULTS 20 screeners and 25 non-screeners were interviewed. Written responses describing reasons for, and circumstances surrounding, non-participation from a further 28 non-screeners were included in the analysis. Thematic analysis identified a range of reactions to the screening invitation, decision-making processes and barriers to participation. These include a perceived or actual lack of need; inability to attend; anxiety and fear about bowel preparation, procedures or hospital; inability or reluctance to self-administer an enema; beliefs about low susceptibility to bowel cancer or treatment and understanding of harm and benefits. The strength, rather than presence, of concerns about the test and perceived need for reassurance were important in the decision to participate for screeners and non-screeners. Decision-making occurs within the context of previous experiences and day-to-day life. CONCLUSIONS Understanding the reasons for non-participation in FS screening can help inform strategies to improve uptake and may be transferable to other screening programmes.
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Affiliation(s)
- N Hall
- School of Pharmacy, Medicine and Health, Durham University, Stockton on Tees, UK
- Faculty of Applied Sciences, University of Sunderland, Sunderland, UK
| | - L Birt
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- University of East Anglia, Norwich, UK
| | - C J Rees
- South Tyneside NHS Foundation Trust, South Shields, UK
- South of Tyne NHS Bowel Cancer Screening Centre, Queen Elizabeth Hospital, Gateshead, UK
| | - F M Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - S Elliot
- Lay Member of Steering Committee, Gateshead, UK
| | - M Ritchie
- South of Tyne NHS Bowel Cancer Screening Centre, Queen Elizabeth Hospital, Gateshead, UK
| | - D Weller
- Cancer Research Centre, Edinburgh University, Edinburgh, UK
| | - G Rubin
- School of Pharmacy, Medicine and Health, Durham University, Stockton on Tees, UK
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Abstract
Accomplishing a compression of morbidity will require prevention of disability, a significant component of illness in older adults. To do this, better understanding is needed of the natural history of functional loss prior to disability. The authors hypothesize that there is an identifiable stage of preclinical disability that will predict future disability and identify a focus for prevention. It is proposed, based on observations in the Johns Hopkins Functional Status Laboratory, that preclinical disability is characterized by persons who perceive no difficulty with performance of a task and yet are found to have either (a) general diminution in activities requiring related abilities, or (b) changes in the performance of specific tasks. Both models are due to impairments. The authors suggest that nondisabled persons use compensatory strategies that minimize functional restrictions resulting from impairment; this may keep functional decline at a preclinical level. These hypotheses, if verified in prospective studies, may provide a basis for early detection of those at risk of disability and suggest effective preventive measures.
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Subash M, Comyn O, Samy A, Qatarneh D, Antonakis S, Mehat M, Tee J, Mansour T, Xing W, Bunce C, Viswanathan A, Rubin G, Weleber R, Peto T, Wickham L, Michaelides M. The Effect of Multispot Laser Panretinal Photocoagulation on Retinal Sensitivity and Driving Eligibility in Patients With Diabetic Retinopathy. JAMA Ophthalmol 2016; 134:666-72. [DOI: 10.1001/jamaophthalmol.2016.0629] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [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]
Affiliation(s)
- Mala Subash
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Oliver Comyn
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Ahmed Samy
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Dania Qatarneh
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Serafeim Antonakis
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Manjit Mehat
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - James Tee
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Tatiana Mansour
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Wen Xing
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Catey Bunce
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Ananth Viswanathan
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Gary Rubin
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Richard Weleber
- Casey Eye Institute, Oregon Health and Science University, Portland
| | - Tunde Peto
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Louisa Wickham
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
| | - Michel Michaelides
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
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Rubin G, Rinott M, Wolovelsky A, Rosenberg L, Shoham Y, Rozen N. A new bromelain-based enzyme for the release of Dupuytren's contracture: Dupuytren's enzymatic bromelain-based release. Bone Joint Res 2016; 5:175-7. [PMID: 27174554 PMCID: PMC4921045 DOI: 10.1302/2046-3758.55.bjr-2016-0072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 03/14/2016] [Indexed: 01/26/2023] Open
Abstract
Objectives Injectable Bromelain Solution (IBS) is a modified investigational derivate of the medical grade bromelain-debriding pharmaceutical agent (NexoBrid) studied and approved for a rapid (four-hour single application), eschar-specific, deep burn debridement. We conducted an ex vivo study to determine the ability of IBS to dissolve-disrupt (enzymatic fasciotomy) Dupuytren’s cords. Materials and Methods Specially prepared medical grade IBS was injected into fresh Dupuytren’s cords excised from patients undergoing surgical fasciectomy. These cords were tested by tension-loading them to failure with the Zwick 1445 (Zwick GmbH & Co. KG, Ulm, Germany) tension testing system. Results We completed a pilot concept-validation study that proved the efficacy of IBS to induce enzymatic fasciotomy in ten cords compared with control in ten cords. We then completed a dosing study with an additional 71 cords injected with IBS in descending doses from 150 mg/cc to 0.8 mg/cc. The dosing study demonstrated that the minimal effective dose of 0.5 cc of 6.25 mg/cc to 5 mg/cc could achieve cord rupture in more than 80% of cases. Conclusions These preliminary results indicate that IBS may be effective in enzymatic fasciotomy in Dupuytren’s contracture. Cite this article: Dr G. Rubin. A new bromelain-based enzyme for the release of Dupuytren’s contracture: Dupuytren’s enzymatic bromelain-based release. Bone Joint Res 2016;5:175–177. DOI: 10.1302/2046-3758.55.BJR-2016-0072.
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Affiliation(s)
- G Rubin
- Orthopaedic Department, Central Emek Hospital, Afula, Israel
| | - M Rinott
- Orthopaedic Department, Central Emek Hospital, Afula, Israel
| | - A Wolovelsky
- Orthopaedic Department, Central Emek Hospital, Afula, Israel
| | - L Rosenberg
- Orthopaedic Department, Central Emek Hospital, Afula, Israel
| | - Y Shoham
- Plastic and Reconstructive Surgery Department and Hand Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - N Rozen
- Plastic and Reconstructive Surgery Department and Hand Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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McCloskey M, Rapp B, Yantis S, Rubin G, Bacon WF, Dagnelie G, Gordon B, Aliminosa D, Boatman DF, Badecker W, Johnson DN, Tusa RJ, Palmer E. A Developmental Deficit in Localizing Objects from Vision. Psychol Sci 2016. [DOI: 10.1111/j.1467-9280.1995.tb00316.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We describe a college student, A H, with a developmental deficit in determining the location of objects from vision The deficit is selective in that (a) localization from auditory or tactile information is intact, (b) A H reports the identity of mislocalized objects accurately, (c) visual localization errors preserve certain parameters of the target location, and (d) visual localization is severely impaired under certain stimulus conditions, but nearly intact under other conditions These results bear on the representation and processing of location information in the visual system, and also have implications for understanding developmental dyslexia
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Rosenberg L, Shoham Y, Krieger Y, Rubin G, Sander F, Koller J, David K, Egosi D, Ahuja R, Singer A. Minimally invasive burn care: a review of seven clinical studies of rapid and selective debridement using a bromelain-based debriding enzyme (Nexobrid®). Ann Burns Fire Disasters 2015; 28:264-274. [PMID: 27777547 PMCID: PMC5068895] [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] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 07/03/2015] [Indexed: 06/06/2023]
Abstract
Current surgical and non-surgical eschar removal-debridement techniques are invasive or ineffective. A bromelainbased rapid and selective enzymatic debriding agent was developed to overcome these disadvantages and compared with the standard of care (SOC). The safety and efficacy of a novel Debriding Gel Dressing (DGD) was determined in patients with deep partial and full thickness burns covering up to 67% total body surface area (TBSA). This review summarizes data from seven studies, four of which were randomized clinical trials that included a SOC or control vehicle. DGD eschar debridement efficacy was >90% in all studies, comparable to the SOC and significantly greater than the control vehicle. The total area excised was less in patients treated with DGD compared with the control vehicle (22.9% vs. 73.2%, P<0.001) or the surgical/non-surgical SOC (50.5%, P=0.006). The incidence of surgical debridement in patients treated with DGD was lower than the SOC (40/163 [24.5%] vs. 119/170 [70.0%], P0.001). Less autografting was used in all studies. Long-term scar quality and function were similar in DGD- and SOCtreated. DGD is a safe and effective method of burn debridement that offers an alternative to surgical and non-surgical SOC.
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Affiliation(s)
- L. Rosenberg
- Department of Plastic and Reconstructive Surgery and the burn Unit, Soroka University medical Centre, Faculty of health Sciences, ben-Gurion University, beer-Sheva, israel
- Cleft Lip and Palate and Craniofacial Deformities Unit, Department of Plastic Surgery, meir hospital, kfar Saba, israel
- Clinical and medical Departments, mediWound LTD, Yavneh, israel
| | - Y. Shoham
- Department of Plastic and Reconstructive Surgery and the burn Unit, Soroka University medical Centre, Faculty of health Sciences, ben-Gurion University, beer-Sheva, israel
| | - Y. Krieger
- Department of Plastic and Reconstructive Surgery and the burn Unit, Soroka University medical Centre, Faculty of health Sciences, ben-Gurion University, beer-Sheva, israel
| | - G. Rubin
- Department of orthopedics, haemek hospital, Afula, israel
| | - F. Sander
- Unfallkrankenhaus berlin, Centre for Severe burns with Plastic Surgery, berlin, Germany
| | - J. Koller
- Department of Plastic Surgery and burn Unit, University hospital, bratislava, Slovakia
| | - K. David
- Clinical and medical Departments, mediWound LTD, Yavneh, israel
| | - D. Egosi
- Department of Plastic and Reconstructive Surgery and the burn Unit, Rambam hospital, haifa, israel
| | - R. Ahuja
- Department of burns and Plastic Surgery, Lok nayak hospital and maulana Azad medical College, new Delhi
| | - A.J. Singer
- Department of emergency medicine, Stony brook University, Stony brook, nY
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Day AC, Burr JM, Bunce C, Doré CJ, Sylvestre Y, Wormald RPL, Round J, McCudden V, Rubin G, Wilkins MR. Randomised, single-masked non-inferiority trial of femtosecond laser-assisted versus manual phacoemulsification cataract surgery for adults with visually significant cataract: the FACT trial protocol. BMJ Open 2015; 5:e010381. [PMID: 26614627 PMCID: PMC4663449 DOI: 10.1136/bmjopen-2015-010381] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Cataract is one of the leading causes of low vision in the westernised world, and cataract surgery is one of the most commonly performed operations. Laser platforms for cataract surgery are now available, the anticipated advantages of which are broad and may include better visual outcomes through greater precision and reproducibility, and improved safety. FACT is a randomised single masked non-inferiority trial to establish whether laser-assisted cataract surgery is as good as or better than standard manual phacoemulsification. METHODS AND ANALYSIS 808 patients aged 18 years and over with visually significant cataract will be randomised to manual phacoemulsification cataract surgery (standard care) or laser-assisted cataract surgery (intervention arm). Outcomes will be measured at 3 and 12 months after surgery. The primary clinical outcome is uncorrected distance visual acuity (UDVA, logMAR) at 3 months in the study eye recorded by an observer masked to the trial group. Secondary outcomes include UDVA at 12 months, corrected distance visual acuity at 3 and 12 months, complications, endothelial cell loss, patient-reported outcome measures and a health economic analysis conforming to National Institute for Health and Care Excellence standards. ETHICS AND DISSEMINATION Research Ethics Committee Approval was obtained on 6 February 2015, ref: 14/LO/1937. Current protocol: v2.0 (08/04/2015). Study findings will be published in peer-reviewed journals. ISRCTN 77602616.
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Affiliation(s)
- Alexander C Day
- UCL Institute of Ophthalmology, University College London, London, UK
- The NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | | | - Catey Bunce
- UCL Institute of Ophthalmology, University College London, London, UK
- The NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | | | | | - Richard P L Wormald
- UCL Institute of Ophthalmology, University College London, London, UK
- The NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Jeff Round
- UCL Comprehensive Clinical Trials Unit, London, UK
| | | | - Gary Rubin
- UCL Institute of Ophthalmology, University College London, London, UK
- The NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Mark R Wilkins
- The NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
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Rubin G, Palti R, Gurevitz S, Yaffe B. Free myocutaneous flap transfer to treat congenital Volkmann's contracture of the forearm. J Hand Surg Eur Vol 2015; 40:614-9. [PMID: 24664161 DOI: 10.1177/1753193414528850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 02/28/2014] [Indexed: 02/03/2023]
Abstract
The purpose of this study is to report our experience with free functional muscle transfer procedures for the late sequelae of the rare condition of congenital Volkmann's ischaemic contracture of the forearm. Four children, with an average age of 9.5 years (range 1.5-17), were treated and were followed for a mean of 6 years (range 1-14). Two patients had dorsal forearm contractures, and two had both flexor and extensor forearm contractures. We carried out free functional muscle transfers to replace the flexor or extensor muscles. The functional result was assessed according to the classification system of Hovius and Ultee. All patients had wrist contractures and skeletal involvement with limb length discrepancy that influenced the outcome. All five transferred muscles survived and improved the function of the hand in three of the four patients. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- G Rubin
- Hand Surgery Department, Sheba Medical Center, Tel Hashomer, Israel Faculty of Medicine, Technion, Haifa, Israel
| | - R Palti
- Hand Surgery Department, Sheba Medical Center, Tel Hashomer, Israel
| | - S Gurevitz
- Hand Surgery Department, Sheba Medical Center, Tel Hashomer, Israel
| | - B Yaffe
- Hand Surgery Department, Sheba Medical Center, Tel Hashomer, Israel
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39
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Abstract
BACKGROUND Recent technological developments, such as the near universal spread of mobile phones and portable computers and improvements in the accessibility features of these devices, give children and young people with low vision greater independent access to information. Some electronic technologies, such as closed circuit TV, are well established low vision aids and newer versions, such as electronic readers or off-the shelf tablet computers, may offer similar functionalities with easier portability and at lower cost. OBJECTIVES To assess the effect of electronic assistive technologies on reading, educational outcomes and quality of life in children and young people with low vision. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2014), EMBASE (January 1980 to October 2014), the Health Technology Assessment Programme (HTA) (www.hta.ac.uk/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 30 October 2014. SELECTION CRITERIA We intended to include randomised controlled trials (RCTs) and quasi-RCTs in this review. We planned to include trials involving children between the ages of 5 and 16 years with low vision as defined by, or equivalent to, the WHO 1992 definition of low vision. We planned to include studies that explore the use of assistive technologies (ATs). These could include all types of closed circuit television/electronic vision enhancement systems (CCTV/EVES), computer technology including tablet computers and adaptive technologies such as screen readers, screen magnification and optical character recognition (OCR). We intended to compare the use of ATs with standard optical aids, which include distance refractive correction (with appropriate near addition for aphakic (no lens)/pseudophakic (with lens implant) patients) and monocular/binoculars for distance and brightfield magnifiers for near. We also planned to include studies that compare different types of ATs with each other, without or in addition to conventional optical aids, and those that compare ATs given with or without instructions for use. DATA COLLECTION AND ANALYSIS Independently, two review authors reviewed titles and abstracts for eligibility. They divided studies into categories to 'definitely include', 'definitely exclude' and 'possibly include', and the same two authors made final judgements about inclusion/exclusion by obtaining full-text copies of the studies in the 'possibly include' category. MAIN RESULTS We did not identify any randomised controlled trials in this subject area. AUTHORS' CONCLUSIONS High-quality evidence about the usefulness of electronic AT for children and young people with visual impairment is needed to inform the choice healthcare and education providers and family have to make when selecting a technology. Randomised controlled trials are needed to assess the impact of AT. Research protocols should carefully select outcomes relevant not only to the scientific community, but more importantly to families and teachers. Functional outcomes such as reading accuracy, comprehension and speed should be recorded, as well as the impact of AT on independent learning and quality of life.
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Affiliation(s)
- Rachel Thomas
- Moorfields at Bedford HospitalOptometryKempston RoadBedfordUKMK42 9DJ
| | - Lucy Barker
- Moorfields Eye Hospital NHS Foundation Trust162 City RoadLondonUKEC1V 2PD
| | - Gary Rubin
- Institute of OphthalmologyBath StreetLondonUKEC1V 9EL
| | - Annegret Dahlmann‐Noor
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology162 City RoadLondonUKEC1V 2PD
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Hungin APS, Becher A, Cayley B, Heidelbaugh JJ, Muris JWM, Rubin G, Seifert B, Russell A, De Wit NJ. Irritable bowel syndrome: an integrated explanatory model for clinical practice. Neurogastroenterol Motil 2015; 27:750-63. [PMID: 25703486 DOI: 10.1111/nmo.12524] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 01/13/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although irritable bowel syndrome (IBS) is a symptom-based diagnosis, clinicians' management of and communication about the disorder is often hampered by an unclear conceptual understanding of the nature of the problem. We aimed to elucidate an integrated explanatory model (EM) for IBS from the existing literature for pragmatic use in the clinical setting. METHODS Systematic and exploratory literature searches were performed in PubMed to identify publications on IBS and EMs. KEY RESULTS The searches did not identify a single, integrated EM for IBS. However, three main hypotheses were elucidated that could provide components with which to develop an IBS EM: (i) altered peripheral regulation of gut function (including sensory and secretory mechanisms); (ii) altered brain-gut signaling (including visceral hypersensitivity); and (iii) psychological distress. Genetic polymorphisms and epigenetic changes may, to some degree, underlie the etiology and pathophysiology of IBS and could increase the susceptibility to developing the disorder. The three model components also fit into one integrated explanation for abdominal symptoms and changes in stool habit. Additionally, IBS may share a common pathophysiological mechanism with other associated functional syndromes. CONCLUSIONS & INFERENCES It was possible to elucidate an integrated, three-component EM as a basis for clinicians to conceptualize the nature of IBS, with the potential to contribute to better diagnosis and management, and dialog with sufferers.
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Affiliation(s)
- A P S Hungin
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, UK
| | - A Becher
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, UK.,Research and Evaluation Unit, Oxford PharmaGenesis Ltd, Oxford, UK
| | - B Cayley
- Department of Family Medicine, University of Wisconsin, Madison, WI, USA
| | - J J Heidelbaugh
- Departments of Family Medicine and Urology, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - J W M Muris
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - G Rubin
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, UK
| | - B Seifert
- Institute of General Practice, Charles University, Praha, Czech Republic
| | - A Russell
- Department of Anthropology, Durham University, Durham, UK
| | - N J De Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Bainbridge JWB, Mehat MS, Sundaram V, Robbie SJ, Barker SE, Ripamonti C, Georgiadis A, Mowat FM, Beattie SG, Gardner PJ, Feathers KL, Luong VA, Yzer S, Balaggan K, Viswanathan A, de Ravel TJL, Casteels I, Holder GE, Tyler N, Fitzke FW, Weleber RG, Nardini M, Moore AT, Thompson DA, Petersen-Jones SM, Michaelides M, van den Born LI, Stockman A, Smith AJ, Rubin G, Ali RR. Long-term effect of gene therapy on Leber's congenital amaurosis. N Engl J Med 2015; 372:1887-97. [PMID: 25938638 PMCID: PMC4497809 DOI: 10.1056/nejmoa1414221] [Citation(s) in RCA: 526] [Impact Index Per Article: 58.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mutations in RPE65 cause Leber's congenital amaurosis, a progressive retinal degenerative disease that severely impairs sight in children. Gene therapy can result in modest improvements in night vision, but knowledge of its efficacy in humans is limited. METHODS We performed a phase 1-2 open-label trial involving 12 participants to evaluate the safety and efficacy of gene therapy with a recombinant adeno-associated virus 2/2 (rAAV2/2) vector carrying the RPE65 complementary DNA, and measured visual function over the course of 3 years. Four participants were administered a lower dose of the vector, and 8 were administered a higher dose. In a parallel study in dogs, we investigated the relationship among vector dose, visual function, and electroretinography (ERG) findings. RESULTS Improvements in retinal sensitivity were evident, to varying extents, in six participants for up to 3 years, peaking at 6 to 12 months after treatment and then declining. No associated improvement in retinal function was detected by means of ERG. Three participants had intraocular inflammation, and two had clinically significant deterioration of visual acuity. The reduction in central retinal thickness varied among participants. In dogs, RPE65 gene therapy with the same vector at lower doses improved vision-guided behavior, but only higher doses resulted in improvements in retinal function that were detectable with the use of ERG. CONCLUSIONS Gene therapy with rAAV2/2 RPE65 vector improved retinal sensitivity, albeit modestly and temporarily. Comparison with the results obtained in the dog model indicates that there is a species difference in the amount of RPE65 required to drive the visual cycle and that the demand for RPE65 in affected persons was not met to the extent required for a durable, robust effect. (Funded by the National Institute for Health Research and others; ClinicalTrials.gov number, NCT00643747.).
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Affiliation(s)
- James W B Bainbridge
- From the UCL (University College London) Institute of Ophthalmology (J.W.B.B., M.S.M., V.S., S.J.R., S.E.B., C.R., A.G., F.M.M., S.G.B., P.J.G., V.A.L., K.B., A.V., G.E.H., F.W.F., M.N., A.T.M., M.M., A.S., A.J.S., G.R., R.R.A.) and the Department of Civil, Environmental, and Geomatic Engineering (N.T.), UCL, and Moorfields Eye Hospital (J.W.B.B., M.S.M., V.S., S.J.R., A.G., K.B., G.H., A.M., M.M.), London, and the Department of Psychology, Durham University, Durham (M.N.) - all in the United Kingdom; the College of Veterinary Medicine, Michigan State University, East Lansing (F.M.M., S.M.P.-J.), and the Kellogg Eye Center, University of Michigan Medical School, Ann Arbor (K.L.F., D.A.T., R.R.A.); the Center for Human Genetics, KU Leuven (T.J.L.R.), and the Department of Ophthalmology, UZ Leuven, Campus Sint-Rafaël (I.C.) - both in Leuven, Belgium; Rotterdam Eye Hospital, Rotterdam, the Netherlands (S.Y., L.I.B.); and the Oregon Retinal Degeneration Center, Ophthalmic Genetics Service, Casey Eye Institute, Oregon Health and Science University, Portland (R.G.W.)
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Mitchell ED, Rubin G, Merriman L, Macleod U. The role of primary care in cancer diagnosis via emergency presentation: qualitative synthesis of significant event reports. Br J Cancer 2015; 112 Suppl 1:S50-6. [PMID: 25734395 PMCID: PMC4385976 DOI: 10.1038/bjc.2015.42] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Patients diagnosed with cancer in the context of an emergency presentation (EP) have poorer outcomes. It is often assumed that such patients present to the emergency department without consulting their general practitioner (GP). Little work has been done to identify primary care involvement before hospital attendance. METHODS Participating primary care practices completed a significant event audit (SEA) report for the last patient diagnosed with cancer as a result of an EP. Accounts were synthesised and a qualitative approach to analysis undertaken. RESULTS SEAs for 222 patients were analysed. A range of cancers were included, the most common being lung (32.4%) and upper gastrointestinal (19.8%). In most cases, patients had contact with their practice before diagnosis, primarily in the period immediately before admission. In only eight cases had there been no input from primary care. Accounts of protracted primary care contact generally demonstrated complexity, often related to comorbidity, patient-mediated factors or reassurance provided by negative investigations. Learning points identified by practices centred on the themes of presentation and diagnosis, consultation and safety-netting, communication and system issues, patient factors and referral guidelines. CONCLUSIONS There is extensive primary care input into patients whose diagnosis results from EP, and for the most part potential 'delay' in referral can be reasonably explained by the complexity of the presentation or by coexisting patient factors.
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Affiliation(s)
- E D Mitchell
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds LS2 9LJ, UK
- E-mail:
| | - G Rubin
- Durham University, School of Medicine, Pharmacy and Health, Wolfson Building, Queen's Campus, University Boulevard, Stockton-on-Tees TS17 6BH, UK
| | - L Merriman
- North Derbyshire Clinical Commissioning Group, The Springs Health Centre, Recreation Close, Clowne, Chesterfield S43 4PL, UK
| | - U Macleod
- Hull York Medical School, University of Hull, Hertford Building, Cottingham Road, Hull HU6 7RX, UK
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Walter FM, Rubin G, Bankhead C, Morris HC, Hall N, Mills K, Dobson C, Rintoul RC, Hamilton W, Emery J. Symptoms and other factors associated with time to diagnosis and stage of lung cancer: a prospective cohort study. Br J Cancer 2015; 112 Suppl 1:S6-13. [PMID: 25734397 PMCID: PMC4385970 DOI: 10.1038/bjc.2015.30] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND This prospective cohort study aimed to identify symptom and patient factors that influence time to lung cancer diagnosis and stage at diagnosis. METHODS Data relating to symptoms were collected from patients upon referral with symptoms suspicious of lung cancer in two English regions; we also examined primary care and hospital records for diagnostic routes and diagnoses. Descriptive and regression analyses were used to investigate associations between symptoms and patient factors with diagnostic intervals and stage. RESULTS Among 963 participants, 15.9% were diagnosed with primary lung cancer, 5.9% with other thoracic malignancies and 78.2% with non-malignant conditions. Only half the cohort had an isolated first symptom (475, 49.3%); synchronous first symptoms were common. Haemoptysis, reported by 21.6% of cases, was the only initial symptom associated with cancer. Diagnostic intervals were shorter for cancer than non-cancer diagnoses (91 vs 124 days, P=0.037) and for late-stage than early-stage cancer (106 vs 168 days, P=0.02). Chest/shoulder pain was the only first symptom with a shorter diagnostic interval for cancer compared with non-cancer diagnoses (P=0.003). CONCLUSIONS Haemoptysis is the strongest symptom predictor of lung cancer but occurs in only a fifth of patients. Programmes for expediting earlier diagnosis need to focus on multiple symptoms and their evolution.
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Affiliation(s)
- F M Walter
- 1] Department of Public Health & Primary Care, University of Cambridge, Cambridge CB1 8RN, UK [2] General Practice & Primary Care Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - G Rubin
- School of Medicine, Pharmacy & Health, Durham University, Wolfson Building, Stockton on Tees TS17 6BH, UK
| | - C Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - H C Morris
- Department of Public Health & Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - N Hall
- School of Medicine, Pharmacy & Health, Durham University, Wolfson Building, Stockton on Tees TS17 6BH, UK
| | - K Mills
- Department of Public Health & Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - C Dobson
- School of Medicine, Pharmacy & Health, Durham University, Wolfson Building, Stockton on Tees TS17 6BH, UK
| | - R C Rintoul
- Department of Thoracic Oncology, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
| | - W Hamilton
- University of Exeter, College House, St Luke's Campus, Exeter EX2 4TE, UK
| | - J Emery
- 1] Department of Public Health & Primary Care, University of Cambridge, Cambridge CB1 8RN, UK [2] General Practice & Primary Care Academic Centre, University of Melbourne, Melbourne, Victoria, Australia [3] Department of General Practice, University of Western Australia, Perth, Western Australia, Australia
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Rubin G, Gildea C, Wild S, Shelton J, Ablett-Spence I. Assessing the impact of an English national initiative for early cancer diagnosis in primary care. Br J Cancer 2015; 112 Suppl 1:S57-64. [PMID: 25734381 PMCID: PMC4385977 DOI: 10.1038/bjc.2015.43] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The Cancer Networks Supporting Primary Care programme was a National Health Service (NHS) initiative in England between 2011 and 2013 that aimed to better understand and improve referral practices for suspected cancer. METHODS A mixed methods evaluation using semi-structured interviews with purposefully sampled key stakeholders and an analysis of Cancer Waiting Times and Hospital Episode Statistics data for all 8179 practices in England were undertaken. We compared periods before (2009/10) and at the end (2012/13) of the initiative for practices taking up any one of four specified quality improvement initiatives expected to change referral practice in the short to medium term and those that did not. RESULTS Overall, 38% of general practices were involved in at least one of four quality improvement activities (clinical audit, significant event analysis, use of risk assessment tools and development of practice plans). Against an overall 29% increase in urgent cancer referrals between 2009/10 and 2012/13, these practices had a significantly higher increase in referral rate, with reduced between-practice variation. There were no significant differences between the two groups in conversion, detection or emergency presentation rates. Key features of successful implementation at practice and network level reported by participants included leadership, organisational culture and physician involvement. Concurrent health service reforms created organisational uncertainty and limited the programme's effectiveness. CONCLUSIONS Specific primary care initiatives promoted by cancer networks had an additional and positive impact on urgent referrals for suspected cancer. Successful engagement with the programmes depended on effective and well-supported leadership by cancer networks and their general practitioner (GP) leads.
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Affiliation(s)
- G Rubin
- School of Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University, Queen's Campus, Stockton-on-Tees TS17 6BH, UK
| | - C Gildea
- PHE Knowledge and Intelligence Team (East Midlands), 5 Old Fulwood Road, Sheffield S10 3TG, UK
| | - S Wild
- PHE Knowledge and Intelligence Team (East Midlands), 5 Old Fulwood Road, Sheffield S10 3TG, UK
| | - J Shelton
- Care Quality Commission, 103-105 Bunhill Row, London EC1Y 8TG, UK
| | - I Ablett-Spence
- School of Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University, Queen's Campus, Stockton-on-Tees TS17 6BH, UK
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Abstract
BACKGROUND Low vision in childhood is a significant barrier to learning and development, particularly for reading and education. Optical low vision aids may be used to maximise the child's functional vision. The World Health Organization (WHO) has previously highlighted the importance of the use of low vision aids in managing children with visual impairment across the world. OBJECTIVES To assess the effect of optical low vision aids on reading in children and young people with low vision. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to January 2015), EMBASE (January 1980 to January 2015), the Health Technology Assessment Programme (HTA) (www.hta.ac.uk/), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 8 January 2015.We also used manual searching to check the references listed in retrieved articles. Manufacturers of low vision aids were contacted to request any information about studies or research regarding their products. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs) and quasi-RCTs where any optical low vision aid was compared to standard refractive correction in children and young people aged between 5 and 16 years of age with low vision as defined by the WHO. We planned to include within-person design studies where the order of presentation of devices was randomised. DATA COLLECTION AND ANALYSIS Two authors independently reviewed the search results for eligibility . MAIN RESULTS No studies met the inclusion criteria for this review. AUTHORS' CONCLUSIONS There is a lack of good quality evidence regarding the use of optical low vision aids in children and young people. As such, no implications for practice can be drawn. We believe future research should include functional outcome measures such as reading speed, accuracy and comprehension, as well as the effect of low vision aids on quality of life, in order to truly assess and compare the effect of these devices on a child's life and development.
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Affiliation(s)
- Lucy Barker
- Moorfields Eye Hospital NHS Foundation Trust162 City RoadLondonUKEC1V 2PD
| | - Rachel Thomas
- Moorfields at Bedford HospitalOptometryKempston RoadBedfordUKMK42 9DJ
| | - Gary Rubin
- Institute of OphthalmologyBath StreetLondonUKEC1V 9EL
| | - Annegret Dahlmann‐Noor
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology162 City RoadLondonUKEC1V 2PD
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Wood J, McKendrick A, Owsley C, Rubin G. Feature issue: visual function and the ageing visual system. Ophthalmic Physiol Opt 2015; 34:387-9. [PMID: 25047244 DOI: 10.1111/opo.12144] [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: 11/30/2022]
Affiliation(s)
- Joanne Wood
- School of Optometry and Vision Science, Queensland University of Technology, Brisbane, Australia.
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Loutfy M, Raboud J, Thompson C, Tseng A, Abdurrahman Z, Kovacs C, Rachlis A, Phillips E, Rubin G, Gough K, Walmsley S. Clinical Impact of Double Protease Inhibitor Boosting with Lopinavir/Ritonavir and Amprenavir as Part of Salvage Antiretroviral Therapy. HIV Clinical Trials 2015; 4:301-10. [PMID: 14583846 DOI: 10.1310/7lyw-gqff-wprq-k3qw] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Double protease inhibitor (PI) boosting is being explored as a new strategy in salvage antiretroviral (ARV) therapy. However, if a negative drug interaction leads to decreased drug levels of either or both PIs, double PI boosting could lead to decreased virologic response. A negative drug interaction has been described between amprenavir (APV) and lopinavir/ritonavir (LPV/r). This observational cohort study assessed the virologic impact of the addition of APV to a salvage ARV regimen, which also contains LPV/r, compared to a regimen containing LPV/r alone. METHOD Patients initiated on a salvage ARV regimen that included LPV/r obtained from the expanded access program in Toronto, Canada, were evaluated. APV (600-1,200 mg bid) was added at the discretion of the treating physician. RESULTS Using multivariate Cox proportional hazards models, we found that the addition of APV to a LPV/r-containing salvage regimen was not significantly associated with time to virologic suppression (< 50 copies/mL; adjusted hazard ratio [HR] = 0.75, p =.12) or with time to virologic rebound (adjusted HR = 1.46, p =.34). Those patients who received higher doses of APV had an increased chance of virologic suppression (p =.03). In a subset of 27 patients, the median LPV C(trough) was significantly lower in patients receiving APV (p =.04), and the median APV C(trough) was reduced compared to reported controls. CONCLUSION Our data do not support an additional benefit in virologic reduction of double boosting with APV and LPV/r relative to LPV/r alone in salvage ARV therapy. Our study's limitations include its retrospective nature and the imbalance between the two groups potentially confounding the results. Although these factors were adjusted for in the multivariate analysis, a prospective randomized controlled trial is warranted to confirm our findings.
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Affiliation(s)
- Mona Loutfy
- Immune Deficiency Treatment Centre, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
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Muscat J, Rubin G. PB.17. Are patients who have had total body irradiation at similar risk of breast cancer to those having mantle radiotherapy? A review of the evidence and suggestions on breast imaging surveillance. Breast Cancer Res 2014. [PMCID: PMC4243143 DOI: 10.1186/bcr3736] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Sivaprasad S, Arden G, Prevost AT, Crosby-Nwaobi R, Holmes H, Kelly J, Murphy C, Rubin G, Vasconcelos J, Hykin P. A multicentre phase III randomised controlled single-masked clinical trial evaluating the clinical efficacy and safety of light-masks at preventing dark-adaptation in the treatment of early diabetic macular oedema (CLEOPATRA): study protocol for a randomised controlled trial. Trials 2014; 15:458. [PMID: 25417120 PMCID: PMC4255925 DOI: 10.1186/1745-6215-15-458] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [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: 04/20/2014] [Accepted: 11/05/2014] [Indexed: 11/30/2022] Open
Abstract
Background This study will evaluate hypoxia, as a novel concept in the pathogenesis of diabetic macular oedema (DMO). As the oxygen demand of the eye is maximum during dark-adaptation, we hypothesize that wearing light-masks during sleep will cause regression and prevent the development and progression of DMO. The study protocol comprises both an efficacy and mechanistic evaluation to test this hypothesis. Method/Design This is a phase III randomised controlled single-masked multicentre clinical trial to test the clinical efficacy of light-masks at preventing dark-adaptation in the treatment of non-central DMO. Three hundred patients with non-centre-involving DMO in at least one eye will be randomised 1:1 to light-masks and control masks (with no light) to be used during sleep at night for a period of 24 months. The primary outcome is regression of non-central oedema by assessing change in the zone of maximal retinal thickness at baseline on optical coherence tomography (SD-OCT). Secondary outcomes will evaluate the prevention of development and progression of DMO by assessing changes in retinal thickness in different regions of the macula, macular volume, refracted visual acuity and level of retinopathy. Safety parameters will include sleep disturbance. Adverse events and measures of compliance will be assessed over 24 months. Participants recruited to the mechanistic sub-study will have additional retinal oximetry, multifocal electroretinography (ERG) and microperimetry to evaluate the role of hypoxia by assessing and comparing changes induced by supplemental oxygen and the light-masks at 12 months. Discussion The outcomes of this study will provide insight into the pathogenesis of DMO and provide evidence on whether a simple, non-invasive device in the form of a light-mask can help prevent the progression to centre-involving DMO and visual impairment in people with diabetes.
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Affiliation(s)
- Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, 162, City Road, London EC1V 2PD, England.
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Hungin APS, Molloy-Bland M, Claes R, Heidelbaugh J, Cayley WE, Muris J, Seifert B, Rubin G, de Wit N. Systematic review: the perceptions, diagnosis and management of irritable bowel syndrome in primary care--a Rome Foundation working team report. Aliment Pharmacol Ther 2014; 40:1133-45. [PMID: 25230281 DOI: 10.1111/apt.12957] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 04/29/2014] [Accepted: 08/27/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To review studies on the perceptions, diagnosis and management of irritable bowel syndrome (IBS) in primary care. METHODS Systematic searches of PubMed and Embase. RESULTS Of 746 initial search hits, 29 studies were included. Relatively few primary care physicians were aware of (2-36%; nine studies) or used (0-21%; six studies) formal diagnostic criteria for IBS. Nevertheless, most could recognise the key IBS symptoms of abdominal pain, bloating and disturbed defaecation. A minority of primary care physicians [7-32%; one study (six European countries)] preferred to refer patients to a specialist before making an IBS diagnosis, and few patients [4-23%; three studies (two European, one US)] were referred to a gastroenterologist by their primary care physician. Most PCPs were unsure about IBS causes and treatment effectiveness, leading to varied therapeutic approaches and broad but frequent use of diagnostic tests. Diagnostic tests, including colon investigations, were more common in older patients (>45 years) than in younger patients [<45 years; five studies (four European, one US)]. CONCLUSIONS There has been much emphasis about the desirability of an initial positive diagnosis of IBS. While it appears most primary care physicians do make a tentative IBS diagnosis from the start, they still tend to use additional testing to confirm it. Although an early, positive diagnosis has advantages in avoiding unnecessary investigations and costs, until formal diagnostic criteria are conclusively shown to sufficiently exclude organic disease, bowel investigations, such as colonoscopy, will continue to be important to primary care physicians.
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Affiliation(s)
- A P S Hungin
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, UK
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