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West CT, West MA, Mirnezami AH, Drami I, Denys A, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Pape E, van Ramshorst GH, Aalbers AGJ, Abdul AN, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Angenete E, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brown K, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelen W, Chan KKL, Chang GJ, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovic L, Daniels IR, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Denost QD, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Egger E, Eglinton T, Enrique-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Flatmark K, Fleming F, Flor B, Folkesson J, Foskett K, Frizelle FA, Funder J, Gallego MA, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther N, Glover T, Goffredo P, Golda T, Gomez CM, Griffiths B, Gwenaël F, Harris C, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kaufman M, Kazi M, Kelley SR, Keller DS, Kelly ME, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Kusters M, Lago V, Lakkis Z, Lampe B, Langheinrich MC, Larach T, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Mackintosh M, Mann C, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McDermott FD, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Monson JRT, Morton JR, Mullaney TG, Navarro AS, Neeff H, Negoi I, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock A, Pellino G, Peterson AC, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Quyn A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Smith T, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor C, Taylor D, Tejedor P, Tekin A, Tekkis PP, Teras J, Thanapal MR, Thaysen HV, Thorgersen E, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weber K, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Empty pelvis syndrome: PelvEx Collaborative guideline proposal. Br J Surg 2023; 110:1730-1731. [PMID: 37757457 PMCID: PMC10805575 DOI: 10.1093/bjs/znad301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023]
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 455] [Impact Index Per Article: 227.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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Davies SJ, West MA, Rahman SA, Underwood TJ, Marino LV. Oesophageal cancer: The effect of early nutrition support on clinical outcomes. Clin Nutr ESPEN 2021; 42:117-123. [PMID: 33745564 DOI: 10.1016/j.clnesp.2021.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/07/2021] [Accepted: 02/14/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS Malnutrition is prevalent in oesophageal cancer. Evidence for the use of nutrition support and prehabilitation in this cohort is variable. The aim of this study was to examine the effect of early nutrition support and functional measures of nutritional status on post-operative outcomes in adult patients with oesophageal cancer. METHODS Retrospective review of adults with oesophageal cancer undergoing oesophagectomy (n = 151). Early nutrition support was defined as: oral or enteral nutrition supplementation during neoadjuvant treatment. Late nutrition support defined as: oral or enteral nutrition supplementation prescribed post-operatively. Nutrition outcome measures were; percentage weight loss from 3 to 6 months prior to diagnosis, peri- and post-operatively, and pre-operative assessment of handgrip-strength (HGS). RESULTS Pre-operative weight loss ≥10% was a significant predictor of mortality at 1 year (OR 2.84, 95%CI 1.03-7.83, p = 0.04) independent of tumour stage, adjuvant treatment, age and gender. Adults prescribed early nutrition support during neoadjuvant treatment experienced less weight loss at 12-months post-oesophagectomy compared to adults prescribed late oral nutrition support (p=<0.05). Pre-operative HGS measurements were not a useful predictor of postoperative complications (p = 0.2), length of stay (p = 0.9) or 90-day mortality (p = 0.6). CONCLUSIONS Pre-operative weight loss ≥10% was associated with mortality. Early nutrition support was associated with less weight loss at 12-months post-operatively. Pre-operative HGS measures did not have prognostic value as a stand-alone measure. Future work should investigate the efficacy of early nutrition support in reducing both pre- and post-operative weight loss to improve nutritional status and surgical outcomes as part of a multimodal prehabilitation programme in adults with oesophageal cancer.
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Affiliation(s)
- S J Davies
- Department of Dietetics/ Speech and Language Therapy, University Hospital NHS Foundation Trust Southampton, Tremona Road, Southampton, SO16 6YD, UK.
| | - M A West
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - S A Rahman
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - T J Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - L V Marino
- Department of Dietetics/ Speech and Language Therapy, University Hospital NHS Foundation Trust Southampton, Tremona Road, Southampton, SO16 6YD, UK; NIHR Biomedical Research Centre Southampton, University Hospital NHS Foundation Trust Southampton, UK; Nutrition and Dietetics, Faculty of Health and Well Being, University of Winchester, UK
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4
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Abstract
A video abstract is available at https://youtu.be/LYJPmWunnKE
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Affiliation(s)
- A Bates
- Anaesthesia and Critical Care Research Area, National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, and Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - M A West
- Anaesthesia and Critical Care Research Area, National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, and Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - S Jack
- Anaesthesia and Critical Care Research Area, National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, and Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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5
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Thomas G, West MA, Browning M, Minto G, Swart M, Richardson K, McGarrity L, Jack S, Grocott MPW, Levett DZH. Why women are not small men: sex-related differences in perioperative cardiopulmonary exercise testing. Perioper Med (Lond) 2020; 9:18. [PMID: 32518637 PMCID: PMC7271469 DOI: 10.1186/s13741-020-00148-2] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 05/04/2020] [Indexed: 02/08/2023] Open
Abstract
Background The use of preoperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative outcomes is increasingly prevalent. CPET-derived information enables personalised perioperative care and enhances shared decision-making. Sex-related differences in physical fitness are reported in non-perioperative literature. However, little attention has been paid to sex-related differences in the context of perioperative CPET. Aim We explored differences in the physical fitness variables reported in a recently published multi-centre study investigating CPET before colorectal surgery. We also report the inclusion rate of females in published perioperative CPET cohorts that are shaping guidelines and clinical practice. Methods We performed a post hoc analysis of the trial data of 703 patients who underwent CPET prior to major elective colorectal surgery. We also summarised the female inclusion rate in peer-reviewed published reports of perioperative CPET. Results Fitness assessed using commonly used perioperative CPET variables—oxygen consumption at anaerobic threshold (AT) and peak exercise—was significantly higher in males than in females both before and after correction for body weight. In studies contributing to the development of perioperative CPET, 68.5% of the participants were male. Conclusion To our knowledge, this is the first study to describe differences between males and females in CPET variables used in a perioperative setting. Furthermore, there is a substantial difference between the inclusion rates of males and females in this field. These findings require validation in larger cohorts and may have significant implications for both sexes in the application of CPET in the perioperative setting.
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Affiliation(s)
- G Thomas
- Department of Intensive Care, Spaarne Hospital, Haarlem, The Netherlands
| | - M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - M Browning
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone, Kent, UK
| | - G Minto
- Directorate of Anaesthesia, Derriford Hospital, 9th Floor Terence Lewis Building, Plymouth, UK.,Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - M Swart
- Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - K Richardson
- STRAPH Research Group, School of Sport and Exercise Sciences, University of Kent, Canterbury, UK.,Anaesthesia and Intensive Care Medicine, Medway Maritime Hospital, Gillingham, UK
| | - L McGarrity
- Department of Anaesthesia, University Hospital Crosshouse, Kilmarnock, East Ayrshire, Scotland, UK
| | - S Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
| | - M P W Grocott
- Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
| | - D Z H Levett
- Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
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6
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West MA, Astin R, Moyses HE, Cave J, White D, Levett DZH, Bates A, Brown G, Grocott MPW, Jack S. Exercise prehabilitation may lead to augmented tumor regression following neoadjuvant chemoradiotherapy in locally advanced rectal cancer. Acta Oncol 2019; 58:588-595. [PMID: 30724668 DOI: 10.1080/0284186x.2019.1566775] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Purpose: We evaluate the effect of an exercised prehabilitation programme on tumour response in rectal cancer patients following neoadjuvant chemoradiotherapy (NACRT). Patients and Methods: Rectal cancer patients with (MRI-defined) threatened resection margins who completed standardized NACRT were prospectively studied in a post hoc, explorative analysis of two previously reported clinical trials. MRI was performed at Weeks 9 and 14 post-NACRT, with surgery at Week 15. Patients undertook a 6-week preoperative exercise-training programme. Oxygen uptake (VO2) at anaerobic threshold (AT) wasmeasured at baseline (pre-NACRT), after completion of NACRT and at week 6 (post-NACRT). Tumour related outcome variables: MRI tumour regression grading (ymrTRG) at Week 9 and 14; histopathological T-stage (ypT); and tumour regression grading (ypTRG)) were compared. Results: 35 patients (26 males) were recruited. 26 patients undertook tailored exercise-training with 9 unmatched controls. NACRT resulted in a fall in VO2 at AT -2.0 ml/kg-1/min-1(-1.3,-2.6), p < 0.001. Exercise was shown to reverse this effect. VO2 at AT increased between groups, (post-NACRT vs. week 6) by +1.9 ml/kg-1/min-1(0.6, 3.2), p = 0.007. A significantly greater ypTRG in the exercise group at the time of surgery was found (p = 0.02). Conclusion: Following completion of NACRT, exercise resulted in significant improvements in fitness and augmented pathological tumour regression.
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Affiliation(s)
- M. A. West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - R. Astin
- Department of Medicine, Institute for Sport, Exercise and Health, University College London, London, UK
| | - H. E. Moyses
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - J. Cave
- Department of Oncology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - D. White
- Department of Radiology, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - D. Z. H. Levett
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - A. Bates
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - G. Brown
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
| | - M. P. W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - S. Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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7
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Curtis NJ, West MA, Salib E, Ockrim J, Allison AS, Dalton R, Francis NK. Time from colorectal cancer diagnosis to laparoscopic curative surgery-is there a safe window for prehabilitation? Int J Colorectal Dis 2018; 33:979-983. [PMID: 29574506 DOI: 10.1007/s00384-018-3016-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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] [Accepted: 03/04/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a growing interest in the adoption of formal prehabilitation programmes prior to elective surgery but regulatory targets mandate prompt treatment following cancer diagnosis. We aimed to investigate if time from diagnosis to surgery is linked to short- and long-term outcomes. METHODS An exploratory analysis was performed utilising a dedicated, prospectively populated database. Inclusion criteria were biopsy-proven colorectal adenocarcinoma undergoing elective laparoscopic surgery with curative intent. Demographics, date of diagnosis and surgery was captured with patients dichotomised using 4-, 8- and 12-week time points. All patients were followed in a standardised pathway for 5 years. Overall survival was assessed with the Kaplan-Meier log-rank method. RESULTS Six hundred sixty-eight consecutive patients met inclusion criteria. Mean time from diagnosis to surgery was 53 days (95% CI 48.3-57.8). Identified risk factors for longer time to surgery were males (OR 1.92 [1.2-3.1], p = 0.008), age ≤ 65 (OR 1.9 [1.2-3], p = 0.01), higher ASA scores (p = 0.01) stoma formation (OR 6.9 [4.1-11], p < 0.001) and neoadjuvant treatment (OR 5.06 [3.1-8.3], p < 0.001). There was no association between time to surgery and BMI (p = 0.36), conversion (16.3%, p = 0.5), length of stay (p = 0.33) and readmission or reoperation (p = 0.3). No differences in five-year survival were seen in those operated within 4, 8 and 12 weeks (p = 0.397, p = 0.962 and p = 0.611, respectively). Multivariate analysis showed time from diagnosis to surgery was not associated with five-year overall survival (HR 0.99, p = 0.52). CONCLUSION Time from colorectal cancer diagnosis to curative laparoscopic surgery did not impact on overall survival. This finding may allow preoperative pathway alteration without compromising safety.
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Affiliation(s)
- N J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK.,Department of Surgery and Cancer, Imperial College London, Level 10, St Mary's Hospital, Praed Street, London, W2 1NY, UK
| | - M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - E Salib
- Faculty of Health and Life Sciences, Brownlow Hill, University of Liverpool, Liverpool, L69 7ZX, UK
| | - J Ockrim
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - A S Allison
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - R Dalton
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK. .,Faculty of Science, University of Bath, Wessex House 3.22, Bath, BA2 7AY, UK.
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West MA, Roman A, Sayan E, Primrose JN, Wedge SR, Underwood TJ, Mirnezami AH. A minimum core outcome dataset for the reporting of preclinical chemotherapeutic drug studies: Lessons learned from multiple discordant methodologies in the setting of colorectal cancer. Crit Rev Oncol Hematol 2017; 112:80-102. [PMID: 28325268 DOI: 10.1016/j.critrevonc.2017.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 10/31/2016] [Revised: 01/11/2017] [Accepted: 02/13/2017] [Indexed: 12/27/2022] Open
Abstract
In vivo studies in animal models are critical tools necessary to study the fundamental complexity of carcinogenesis. A constant strive to improve animal models in cancer exists, especially those investigating the use of chemotherapeutic effectiveness. In the present systematic review, colorectal cancer (CRC) is used as an example to highlight and critically evaluate the range of reporting strategies used when investigating chemotherapeutic agents in the preclinical setting. A systematic review examining the methodology and reporting of preclinical chemotherapeutic drug studies using CRC murine models was conducted. A total of 45 studies were included in this systematic review. The literature was found to be highly heterogeneous with various cell lines, animal strains, animal ages and chemotherapeutic compounds/regimens tested, proving difficult to compare outcomes between similar studies or indeed gain any significant insight into which chemotherapeutic regimen caused adverse events. From this analysis we propose a minimum core outcome dataset that could be regarded as a standardised way of reporting results from in vivo experimentation.
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Affiliation(s)
- M A West
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK.
| | - A Roman
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - E Sayan
- Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - J N Primrose
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - S R Wedge
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - T J Underwood
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - A H Mirnezami
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
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West MA, Loughney L, Ambler G, Dimitrov BD, Kelly JJ, Mythen MG, Sturgess R, Calverley PMA, Kendrick A, Grocott MPW, Jack S. The effect of neoadjuvant chemotherapy and chemoradiotherapy on exercise capacity and outcome following upper gastrointestinal cancer surgery: an observational cohort study. BMC Cancer 2016; 16:710. [PMID: 27589870 PMCID: PMC5010720 DOI: 10.1186/s12885-016-2682-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 08/05/2016] [Indexed: 11/13/2022] Open
Abstract
Background In 2014 approximately 21,200 patients were diagnosed with oesophageal and gastric cancer in England and Wales, of whom 37 % underwent planned curative treatments. Potentially curative surgical resection is associated with significant morbidity and mortality. For operable locally advanced disease, neoadjuvant chemotherapy (NAC) improves survival over surgery alone. However, NAC carries the risk of toxicity and is associated with a decrease in physical fitness, which may in turn influence subsequent clinical outcome. Lower levels of physical fitness are associated with worse outcome following major surgery in general and Upper Gastrointestinal Surgery (UGI) surgery in particular. Cardiopulmonary exercise testing (CPET) provides an objective assessment of physical fitness. The aim of this study is to test the hypothesis that NAC prior to upper gastrointestinal cancer surgery is associated with a decrease in physical fitness and that the magnitude of the change in physical fitness will predict mortality 1 year following surgery. Methods This study is a multi-centre, prospective, blinded, observational cohort study of participants with oesophageal and gastric cancer scheduled for neoadjuvant cancer treatment (chemo- and chemoradiotherapy) and surgery. The primary endpoints are physical fitness (oxygen uptake at lactate threshold measured using CPET) and 1-year mortality following surgery; secondary endpoints include post-operative morbidity (Post-Operative Morbidity Survey (POMS)) 5 days after surgery and patient related quality of life (EQ-5D-5 L). Discussion The principal benefits of this study, if the underlying hypothesis is correct, will be to facilitate better selection of treatments (e.g. NAC, Surgery) in patients with oesophageal or gastric cancer. It may also be possible to develop new treatments to reduce the effects of neoadjuvant cancer treatment on physical fitness. These results will contribute to the design of a large, multi-centre trial to determine whether an in-hospital exercise-training programme that increases physical fitness leads to improved overall survival. Trial registration ClinicalTrials.gov NCT01325883 - 29th March 2011.
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Affiliation(s)
- M A West
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK.,Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - L Loughney
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
| | - G Ambler
- Department of Statistical Science, University College London, London, UK
| | - B D Dimitrov
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
| | - J J Kelly
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - M G Mythen
- Centre for Anaesthesia, Institute of Sport Exercise and Health, University College London Hospitals NIHR Biomedical Research Centre, London, UK
| | - R Sturgess
- Department of Gastroenterology, University Hospitals Aintree, Longmoor Road, Liverpool, UK
| | - P M A Calverley
- Department of Respiratory Research, University of Liverpool, University Hospitals Aintree, Longmoor Road, Liverpool, UK
| | - A Kendrick
- Department of Physiological Sciences, University of Bristol, Bristol, UK
| | - M P W Grocott
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK. .,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK.
| | - S Jack
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
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10
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West MA, Asher R, Browning M, Minto G, Swart M, Richardson K, McGarrity L, Jack S, Grocott MPW. Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery. Br J Surg 2016. [PMID: 26914526 DOI: 10.1002/bjs.10112)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery. METHODS Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity. RESULTS Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V˙o2 at θ^L ) and at peak exercise (V˙o2peak ) gave an area under the ROC curve (AUROC) of 0·79 (95 per cent c.i. 0·76 to 0·83; P < 0·001; cut-off 11·1 ml per kg per min) and 0·77 (0·72 to 0·82; P < 0·001; cut-off 18·2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V˙o2 at θ^L 11·1 ml per kg per min or less: odds ratio (OR) 7·56, 95 per cent c.i. 4·44 to 12·86, P < 0·001; V˙o2peak 18·2 ml per kg per min or less: OR 2·15, 1·01 to 4·57, P = 0·047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V˙E /V˙co2 at θ^L ) more than 30·9: OR 1·38, 1·00 to 1·89, P = 0·047); BMI exceeding 27 kg/m2 : OR 1·05, 1·03 to 1·08, P < 0·001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0·30, 0·02 to 0·44; P = 0·033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0·83, 95 per cent c.i. 0·79 to 0·87). No adverse clinical events occurred during CPET across the six centres. CONCLUSION These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.
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Affiliation(s)
- M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Asher
- Cancer Research UK Liverpool Cancer Trials Unit, Liverpool, UK
| | - M Browning
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - G Minto
- Directorate of Anaesthesia, Derriford Hospital, Plymouth, UK.,Plymouth University, Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - M Swart
- Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - K Richardson
- Sports Therapy, Physical Activity and Health Research Group, School of Sport and Exercise Sciences, University of Kent, Canterbury, UK.,Anaesthesia and Intensive Care Medicine, Medway Maritime Hospital, Gillingham, UK
| | - L McGarrity
- Department of Anaesthesia, University Hospital Crosshouse, Kilmarnock, UK
| | - S Jack
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - M P W Grocott
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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11
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West MA, Dimitrov BD, Moyses HE, Kemp GJ, Loughney L, White D, Grocott MPW, Jack S, Brown G. Timing of surgery following neoadjuvant chemoradiotherapy in locally advanced rectal cancer - A comparison of magnetic resonance imaging at two time points and histopathological responses. Eur J Surg Oncol 2016; 42:1350-8. [PMID: 27160356 DOI: 10.1016/j.ejso.2016.04.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/17/2016] [Accepted: 04/07/2016] [Indexed: 01/01/2023] Open
Abstract
PURPOSE There is wide inter-institutional variation in the interval between neoadjuvant chemoradiotherapy (NACRT) and surgery for locally advanced rectal cancer. We aimed to assess the association of magnetic resonance imaging (MRI) at 9 and 14 weeks post-NACRT; T-staging (ymrT) and post-NACRT tumour regression grading (ymrTRG) with histopathological outcomes; histopathological T-stage (ypT) and histopathological tumour regression grading (ypTRG) in order to inform decision-making about timing of surgery. PATIENTS AND METHODS We prospectively studied 35 consecutive patients (26 males) with MRI-defined resection margin threatened rectal cancer who had completed standardized NACRT. Patients underwent a MRI at Weeks 9 and 14 post-NACRT, and surgery at Week 15. Two readers independently assessed MRIs for ymrT, ymrTRG and volume change. ymrT and ymrTRG were analysed against histopathological ypT and ypTRG as predictors by logistic regression modelling and receiver operating characteristic (ROC) curve analyses. RESULTS Thirty-five patients were recruited. Inter-observer agreement was good for all MR variables (Kappa > 0.61). Considering ypT as an outcome variable, a stronger association of favourable ymrTRG and volume change at Week 14 compared to Week 9 was found (ymrTRG - p = 0.064 vs. p = 0.010; Volume change - p = 0.062 vs. p = 0.007). Similarly, considering ypTRG as an outcome variable, a greater association of favourable ymrTRG and volume change at Week 14 compared to Week 9 was found (ymrTRG - p = 0.005 vs. p = 0.042; Volume change - p = 0.004 vs. 0.055). CONCLUSION Following NACRT, greater tumour down-staging and volume reduction was observed at Week 14. Timing of surgery, in relation to NACRT, merits further investigation. TRIAL REGISTRATION NUMBER NCT01325909.
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Affiliation(s)
- M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom.
| | - B D Dimitrov
- Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom.
| | - H E Moyses
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom; National Institute for Health Research, Southampton Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom.
| | - G J Kemp
- Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - L Loughney
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - D White
- Department of Radiology, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom.
| | - M P W Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - S Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - G Brown
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, United Kingdom.
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12
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West MA, Asher R, Browning M, Minto G, Swart M, Richardson K, McGarrity L, Jack S, Grocott MPW. Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery. Br J Surg 2016; 103:744-752. [PMID: 26914526 DOI: 10.1002/bjs.10112] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 09/28/2015] [Accepted: 12/16/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery. METHODS Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity. RESULTS Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V˙o2 at θ^L ) and at peak exercise (V˙o2peak ) gave an area under the ROC curve (AUROC) of 0·79 (95 per cent c.i. 0·76 to 0·83; P < 0·001; cut-off 11·1 ml per kg per min) and 0·77 (0·72 to 0·82; P < 0·001; cut-off 18·2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V˙o2 at θ^L 11·1 ml per kg per min or less: odds ratio (OR) 7·56, 95 per cent c.i. 4·44 to 12·86, P < 0·001; V˙o2peak 18·2 ml per kg per min or less: OR 2·15, 1·01 to 4·57, P = 0·047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V˙E /V˙co2 at θ^L ) more than 30·9: OR 1·38, 1·00 to 1·89, P = 0·047); BMI exceeding 27 kg/m2 : OR 1·05, 1·03 to 1·08, P < 0·001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0·30, 0·02 to 0·44; P = 0·033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0·83, 95 per cent c.i. 0·79 to 0·87). No adverse clinical events occurred during CPET across the six centres. CONCLUSION These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.
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Affiliation(s)
- M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Asher
- Cancer Research UK Liverpool Cancer Trials Unit, Liverpool, UK
| | - M Browning
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - G Minto
- Directorate of Anaesthesia, Derriford Hospital, Plymouth, UK.,Plymouth University, Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - M Swart
- Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - K Richardson
- Sports Therapy, Physical Activity and Health Research Group, School of Sport and Exercise Sciences, University of Kent, Canterbury, UK.,Anaesthesia and Intensive Care Medicine, Medway Maritime Hospital, Gillingham, UK
| | - L McGarrity
- Department of Anaesthesia, University Hospital Crosshouse, Kilmarnock, UK
| | - S Jack
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - M P W Grocott
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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13
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West MA. Preoperative physical fitness assessment, prehabilitation and surgical outcome - a video vignette. Colorectal Dis 2016; 18:215-6. [PMID: 26467122 DOI: 10.1111/codi.13155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/04/2015] [Indexed: 02/08/2023]
Affiliation(s)
- M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, South Academic Block, Mail point 816, Southampton University Hospital, Southampton SO16 6YD, UK.
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Loughney L, West MA, Kemp GJ, Grocott MPW, Jack S. Exercise intervention in people with cancer undergoing neoadjuvant cancer treatment and surgery: A systematic review. Eur J Surg Oncol 2015; 42:28-38. [PMID: 26506862 DOI: 10.1016/j.ejso.2015.09.027] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 09/22/2015] [Accepted: 09/30/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Neoadjuvant cancer treatment decreases physical fitness. Low levels of physical fitness are associated with poor surgical outcome. Exercise training can stimulate skeletal muscle adaptations, such as increased mitochondrial content and improved oxygen uptake capacity that may contribute to improving physical fitness. This systematic review evaluates the evidence in support of exercise training in people with cancer undergoing the "dual hit" of neoadjuvant cancer treatment and surgery. METHODS We conducted a systematic database search of Embase Ovid, Ovid Medline without Revisions, SPORTDiscus, Web of Science, Cochrane Central Register of Controlled Trials Library and ClinicalTrials.gov to identify trials addressing the effect of exercise training in people scheduled for neoadjuvant cancer treatment and surgery. Data extraction and analysis were based on a pre-defined plan. RESULTS The database search yielded 6489 candidate abstracts. Ninety-four references included the required terms. Four studies were eligible for inclusion (breast cancer, locally advanced rectal cancer). All studies reported that exercise training was safe and feasible and that adherence rates were acceptable (66-96%). In-hospital exercise training improves physical fitness however the impact on HRQoL and other clinical important outcomes was uncertain. CONCLUSION This is the first systematic review of the effects of exercise training in people scheduled for "dual-hit" treatment. This evidence synthesis indicates that this approach is safe and feasible but that there are insufficient controlled trials in this area to draw reliable conclusions about the efficacy of such an intervention, the optimal characteristics of the intervention, or the impact on clinical or patient reported outcomes.
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Affiliation(s)
- L Loughney
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
| | - M A West
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, South Academic Block, Tremona Road, Southampton, SO16 6YD, UK
| | - G J Kemp
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Department of Musculoskeletal Biology and MRC - Arthritis Research UK Centre for Integrated Research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - M P W Grocott
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK
| | - S Jack
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK
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15
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Loughney L, West MA, Kemp GJ, Grocott MPW, Jack S. Exercise intervention in people with cancer undergoing adjuvant cancer treatment following surgery: A systematic review. Eur J Surg Oncol 2015; 41:1590-602. [PMID: 26358569 DOI: 10.1016/j.ejso.2015.08.153] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 07/30/2015] [Accepted: 08/04/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Remaining physically active during and after cancer treatment is known to improve associated adverse effects, improve overall survival and reduce the probability of relapse. This systematic review addresses the question: is an exercise training programme beneficial in people with cancer undergoing adjuvant cancer treatment following surgery. METHODS A systematic database search of Embase, Ovid, Medline without Revisions, SPORTDiscus, Web of Science, Cochrane Library and ClinicalTrials.gov for any randomised controlled trials (RCT) or non-RCT addressing the effect of an exercise training programme in those having adjuvant cancer treatment following surgery was conducted. RESULTS The database search yielded 6489 candidate abstracts of which 94 references included the required terms. A total of 17 articles were included in this review. Exercise training is safe and feasible in the adjuvant setting and furthermore may improve measures of physical fitness and health related quality of life (HRQoL). CONCLUSION This is the first systematic review on exercise training interventions in people with cancer undergoing adjuvant cancer treatment following surgery. Due to the lack of adequately powered RCTs in this area, it remains unclear whether exercise training in this context improves clinical outcomes other physical fitness and HRQoL. It remains unclear what is the optimal timing of initiation of an exercise programme and what are the best combinations of elements within an exercise training programme to optimise training efficacy. Furthermore, it is unclear if initiating such exercise programmes at cancer diagnosis may have a long-lasting effect on physically activity throughout the subsequent life course.
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Affiliation(s)
- L Loughney
- Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
| | - M A West
- Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - G J Kemp
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Department of Musculoskeletal Biology and MRC, Arthritis Research UK Centre for Integrated Research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - M P W Grocott
- Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK
| | - S Jack
- Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK
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16
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West MA, Parry M, Asher R, Key A, Walker P, Loughney L, Pintus S, Duffy N, Jack S, Torella F. The Effect of beta-blockade on objectively measured physical fitness in patients with abdominal aortic aneurysms--A blinded interventional study. Br J Anaesth 2015; 114:878-85. [PMID: 25716221 DOI: 10.1093/bja/aev026] [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] [Subscribe] [Scholar Register] [Accepted: 11/03/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Perioperative beta-blockade is widely used, especially before vascular surgery; however, its impact on exercise performance assessed using cardiopulmonary exercise testing (CPET) in this group is unknown. We hypothesized that beta-blocker therapy would significantly improve CPET-derived physical fitness in this group. METHODS We recruited patients with abdominal aortic aneurysms (AAA) of <5.5 cm under surveillance. All patients underwent CPET on and off beta-blockers. Patients routinely prescribed beta-blockers underwent a first CPET on medication. Beta-blockers were stopped for one week before a second CPET. Patients not routinely taking beta-blockers underwent the first CPET off treatment, then performed a second CPET after commencement of bisoprolol for at least 48 h. Oxygen uptake (.VO2) at estimated lactate threshold and .VO2 at peak were primary outcome variables. A linear mixed-effects model was fitted to investigate any difference in adjusted CPET variables on and off beta-blockers. RESULTS Forty-eight patients completed the study. No difference was observed in .VO2 at estimated lactate threshold and .VO2 at peak; however, a significant decrease in .VE/.VCO2 at estimated lactate threshold and peak, an increase in workload at estimated lactate threshold., O2 pulse and heart rate both at estimated lactate threshold and peak was found with beta-blockers. Patients taking beta-blockers routinely (chronic group) had worse exercise performance (lower .VO2 ). CONCLUSIONS Beta blockade has a significant impact on CPET-derived exercise performance, albeit without changing .VO2 at estimated lactate threshold and.VO2 at peak. This supports performance of preoperative CPET on or off beta-blockers depending on local perioperative practice. CLINICAL TRIAL REGISTRATION NCT 02106286.
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Affiliation(s)
- M A West
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
| | - M Parry
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - R Asher
- Cancer Research UK Liverpool Cancer Trials Unit, Waterhouse Building, University of Liverpool, Liverpool, UK
| | - A Key
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - P Walker
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
| | - L Loughney
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK
| | - S Pintus
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building
| | - N Duffy
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - S Jack
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK
| | - F Torella
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Liverpool Vascular & Endovascular Service, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
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17
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West MA, Loughney L, Lythgoe D, Barben CP, Sripadam R, Kemp GJ, Grocott MPW, Jack S. Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study. Br J Anaesth 2014. [PMID: 25274049 DOI: 10.1093/bja/aeu318.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients requiring surgery for locally advanced rectal cancer often additionally undergo neoadjuvant chemoradiotherapy (NACRT), of which the effects on physical fitness are unknown. The aim of this feasibility and pilot study was to investigate the effects of NACRT and a 6 week structured responsive exercise training programme (SRETP) on oxygen uptake [Formula: see text] at lactate threshold ([Formula: see text]) in such patients. METHODS We prospectively studied 39 consecutive subjects (27 males) with T3-4/N+ resection margin threatened rectal cancer who completed standardized NACRT. Subjects underwent cardiopulmonary exercise testing at baseline (pre-NACRT), at week 0 (post-NACRT), and week 6 (post-SRETP). Twenty-two subjects undertook a 6 week SRETP on a training bike (three sessions per week) between week 0 and week 6 (exercise group). These were compared with 17 contemporaneous non-randomized subjects (control group). Changes in [Formula: see text] at [Formula: see text] over time and between the groups were compared using a compound symmetry covariance linear mixed model. RESULTS Of 39 recruited subjects, 22 out of 22 (exercise) and 13 out of 17 (control) completed the study. There were differences between the exercise and control groups at baseline [age, ASA score physical status, World Health Organisation performance status, and Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM) predicted mortality]. In all subjects, [Formula: see text] at [Formula: see text] significantly reduced between baseline and week 0 [-1.9 ml kg(-1) min(-1); 95% confidence interval (CI) -1.3, -2.6; P<0.0001]. In the exercise group, [Formula: see text] at [Formula: see text] significantly improved between week 0 and week 6 (+2.1 ml kg(-1) min(-1); 95% CI +1.3, +2.9; P<0.0001), whereas the control group values were unchanged (-0.7 ml kg(-1) min(-1); 95% CI -1.66, +0.37; P=0.204). CONCLUSIONS NACRT before rectal cancer surgery reduces physical fitness. A structured exercise intervention is feasible post-NACRT and returns fitness to baseline levels within 6 weeks. CLINICAL TRIAL REGISTRATION NCT 01325909.
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Affiliation(s)
- M A West
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - L Loughney
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - D Lythgoe
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Waterhouse Building, Liverpool, UK
| | - C P Barben
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK
| | | | - G J Kemp
- Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - M P W Grocott
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - S Jack
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
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Jack S, West MA, Raw D, Marwood S, Ambler G, Cope TM, Shrotri M, Sturgess RP, Calverley PMA, Ottensmeier CH, Grocott MPW. The effect of neoadjuvant chemotherapy on physical fitness and survival in patients undergoing oesophagogastric cancer surgery. Eur J Surg Oncol 2014. [PMID: 24731268 DOI: 10.1016/j.ejso.2014.03.010)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) followed by surgery for resectable oesophageal or gastric cancer improves outcome when compared with surgery alone. However NAC has adverse effects. We assess here whether NAC adversely affects physical fitness and whether such an effect is associated with impaired survival following surgery. METHODS We prospectively studied 116 patients with oesophageal or gastric cancer to assess the effect of NAC on physical fitness, of whom 89 underwent cardiopulmonary exercise testing (CPET) before NAC and proceeded to surgery. 39 patients were tested after all cycles of NAC but prior to surgery. Physical fitness was assessed by measuring oxygen uptake (VO₂ in ml kg(-1) min(-1)) at the estimated lactate threshold (θL) and at peak exercise (VO₂ peak in ml kg(-1) min(-1)). RESULTS VO₂ at θL and at peak were significantly lower after NAC compared to pre-NAC values: VO₂ at θL 14.5 ± 3.8 (baseline) vs. 12.3 ± 3.0 (post-NAC) ml kg(-1) min(-1); p ≤ 0.001; VO₂ peak 20.8 ± 6.0 vs. 18.3 ± 5.1 ml kg(-1) min(-1); p ≤ 0.001; absolute VO₂ (ml min(-1)) at θL and peak were also lower post-NAC; p ≤ 0.001. Decreased baseline VO₂ at θL and peak were associated with increased one year mortality in patients who completed a full course of NAC and had surgery; p = 0.014. CONCLUSION NAC before cancer surgery significantly reduced physical fitness in the overall cohort. Lower baseline fitness was associated with reduced one-year-survival in patients completing NAC and surgery, but not in patients who did not complete NAC. It is possible that in some patients the harms of NAC may outweigh the benefits. Trials Registry Number: NCT01335555.
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Affiliation(s)
- S Jack
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - M A West
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - D Raw
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - S Marwood
- Liverpool Hope University, Hope Park, Liverpool, United Kingdom.
| | - G Ambler
- Statistical Science, University College London, Torrington Place, London, United Kingdom.
| | - T M Cope
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - M Shrotri
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - R P Sturgess
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - P M A Calverley
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - C H Ottensmeier
- Cancer Sciences Division and Department of Medical Oncology, University Southampton NHS Foundation Trust, Southampton, United Kingdom; NIHR/CR-UK Experimental Cancer Medicine Centre, Southampton, United Kingdom.
| | - M P W Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Southampton NHS Foundation Trust, Southampton, United Kingdom.
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19
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West MA, Loughney L, Lythgoe D, Barben CP, Sripadam R, Kemp GJ, Grocott MPW, Jack S. Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study. Br J Anaesth 2014; 114:244-51. [PMID: 25274049 DOI: 10.1093/bja/aeu318] [Citation(s) in RCA: 223] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients requiring surgery for locally advanced rectal cancer often additionally undergo neoadjuvant chemoradiotherapy (NACRT), of which the effects on physical fitness are unknown. The aim of this feasibility and pilot study was to investigate the effects of NACRT and a 6 week structured responsive exercise training programme (SRETP) on oxygen uptake [Formula: see text] at lactate threshold ([Formula: see text]) in such patients. METHODS We prospectively studied 39 consecutive subjects (27 males) with T3-4/N+ resection margin threatened rectal cancer who completed standardized NACRT. Subjects underwent cardiopulmonary exercise testing at baseline (pre-NACRT), at week 0 (post-NACRT), and week 6 (post-SRETP). Twenty-two subjects undertook a 6 week SRETP on a training bike (three sessions per week) between week 0 and week 6 (exercise group). These were compared with 17 contemporaneous non-randomized subjects (control group). Changes in [Formula: see text] at [Formula: see text] over time and between the groups were compared using a compound symmetry covariance linear mixed model. RESULTS Of 39 recruited subjects, 22 out of 22 (exercise) and 13 out of 17 (control) completed the study. There were differences between the exercise and control groups at baseline [age, ASA score physical status, World Health Organisation performance status, and Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM) predicted mortality]. In all subjects, [Formula: see text] at [Formula: see text] significantly reduced between baseline and week 0 [-1.9 ml kg(-1) min(-1); 95% confidence interval (CI) -1.3, -2.6; P<0.0001]. In the exercise group, [Formula: see text] at [Formula: see text] significantly improved between week 0 and week 6 (+2.1 ml kg(-1) min(-1); 95% CI +1.3, +2.9; P<0.0001), whereas the control group values were unchanged (-0.7 ml kg(-1) min(-1); 95% CI -1.66, +0.37; P=0.204). CONCLUSIONS NACRT before rectal cancer surgery reduces physical fitness. A structured exercise intervention is feasible post-NACRT and returns fitness to baseline levels within 6 weeks. CLINICAL TRIAL REGISTRATION NCT 01325909.
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Affiliation(s)
- M A West
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - L Loughney
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - D Lythgoe
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Waterhouse Building, Liverpool, UK
| | - C P Barben
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK
| | | | - G J Kemp
- Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - M P W Grocott
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - S Jack
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
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West MA, Parry MG, Lythgoe D, Barben CP, Kemp GJ, Grocott MPW, Jack S. Cardiopulmonary exercise testing for the prediction of morbidity risk after rectal cancer surgery. Br J Surg 2014; 101:1166-72. [PMID: 24916313 DOI: 10.1002/bjs.9551] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 03/15/2014] [Accepted: 04/09/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study investigated the relationship between objectively measured physical fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after rectal cancer surgery. METHODS Patients scheduled for rectal cancer surgery underwent preoperative CPET (reported blind to patient characteristics) with recording of morbidity (recorded blind to CPET variables). Non-parametric receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity. RESULTS Of 105 patients assessed, 95 (72 men) were included; ten patients had no surgery and were excluded (3 by choice, 7 owing to unresectable metastasis). Sixty-eight patients had received neoadjuvant treatment. ROC curve analysis of oxygen uptake (V˙o2 ) at estimated lactate threshold (θ^L ) and peak V˙o2 gave an area under the ROC curve of 0·87 (95 per cent confidence interval 0·78 to 0·95; P < 0·001) and 0·85 (0·77 to 0·93; P < 0·001) respectively, indicating that they can help discriminate patients at risk of postoperative morbidity. The optimal cut-off points identified were 10·6 and 18·6 ml per kg per min for V˙o2 at θ^L and peak respectively. CONCLUSION CPET can help predict morbidity after rectal cancer surgery.
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Affiliation(s)
- M A West
- Colorectal Surgery Research Group, Department of Surgery, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK; Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, Liverpool, UK; Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK
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West MA, Loughney L, Barben CP, Sripadam R, Kemp GJ, Grocott MPW, Jack S. The effects of neoadjuvant chemoradiotherapy on physical fitness and morbidity in rectal cancer surgery patients. Eur J Surg Oncol 2014; 40:1421-8. [PMID: 24784775 DOI: 10.1016/j.ejso.2014.03.021] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 03/15/2014] [Accepted: 03/22/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (NACRT) followed by surgery for resectable locally advanced rectal cancer improves outcome compared with surgery alone. Our primary hypothesis was that NACRT impairs objectively-measured physical fitness. We also wished to explore the relationship between fitness and postoperative outcome. METHOD In an observational study, we prospectively studied 27 consecutive patients, of whom 25 undertook cardiopulmonary exercise testing (CPET) 2 weeks before and 7 weeks after standardized NACRT, then underwent surgery. In-hospital post-operative morbidity and mortality were recorded. Patients were followed up to 1 year for mortality. Data was analysed blind to clinical details. Receiver-operating characteristic (ROC) analysis defined the predictive value of CPET for in-hospital morbidity at day 5. RESULTS Oxygen uptake ( [Formula: see text] in ml kg(-1) min(-1)) at estimated lactate threshold (θˆL) and at peak exercise ( [Formula: see text] at peak in ml kg(-1) min(-1)) both significantly decreased post-NACRT: [Formula: see text] at θˆL 12.1 (pre-NACRT) vs. 10.6 (post-NACRT), p < 0.001 (95%CI -1.7, -1.2); [Formula: see text] at peak 18.1 vs. 16.7, p < 0.001 (95%CI -3.1, -1.0). Optimal [Formula: see text] at θˆL and peak pre-NACRT for predicting postoperative morbidity were 12.0 and 18.1 ( [Formula: see text] at θˆL - AUC = 0.71, 77% sensitive and 75% specific; [Formula: see text] at peak - AUC = 0.75, 78% sensitive and 76% specific). Optimal [Formula: see text] at θˆL and peak post-NACRT for predicting postoperative morbidity were 10.7 and 16.7 ( [Formula: see text] at θˆL - AUC = 0.72, 77% sensitive and 83% specific; [Formula: see text] at peak - AUC = 0.80, 85% sensitive and 83% specific). CONCLUSION NACRT before major rectal cancer surgery significantly decreased physical fitness as assessed by CPET. TRIALS REGISTRY NUMBER NCT01334593.
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Affiliation(s)
- M A West
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - L Loughney
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - C P Barben
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom.
| | - R Sripadam
- Clatterbridge Cancer Centre, Wirral, United Kingdom.
| | - G J Kemp
- Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - M P W Grocott
- Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - S Jack
- Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
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Jack S, West MA, Raw D, Marwood S, Ambler G, Cope TM, Shrotri M, Sturgess RP, Calverley PMA, Ottensmeier CH, Grocott MPW. The effect of neoadjuvant chemotherapy on physical fitness and survival in patients undergoing oesophagogastric cancer surgery. Eur J Surg Oncol 2014; 40:1313-20. [PMID: 24731268 DOI: 10.1016/j.ejso.2014.03.010] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 03/14/2014] [Accepted: 03/17/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) followed by surgery for resectable oesophageal or gastric cancer improves outcome when compared with surgery alone. However NAC has adverse effects. We assess here whether NAC adversely affects physical fitness and whether such an effect is associated with impaired survival following surgery. METHODS We prospectively studied 116 patients with oesophageal or gastric cancer to assess the effect of NAC on physical fitness, of whom 89 underwent cardiopulmonary exercise testing (CPET) before NAC and proceeded to surgery. 39 patients were tested after all cycles of NAC but prior to surgery. Physical fitness was assessed by measuring oxygen uptake (VO₂ in ml kg(-1) min(-1)) at the estimated lactate threshold (θL) and at peak exercise (VO₂ peak in ml kg(-1) min(-1)). RESULTS VO₂ at θL and at peak were significantly lower after NAC compared to pre-NAC values: VO₂ at θL 14.5 ± 3.8 (baseline) vs. 12.3 ± 3.0 (post-NAC) ml kg(-1) min(-1); p ≤ 0.001; VO₂ peak 20.8 ± 6.0 vs. 18.3 ± 5.1 ml kg(-1) min(-1); p ≤ 0.001; absolute VO₂ (ml min(-1)) at θL and peak were also lower post-NAC; p ≤ 0.001. Decreased baseline VO₂ at θL and peak were associated with increased one year mortality in patients who completed a full course of NAC and had surgery; p = 0.014. CONCLUSION NAC before cancer surgery significantly reduced physical fitness in the overall cohort. Lower baseline fitness was associated with reduced one-year-survival in patients completing NAC and surgery, but not in patients who did not complete NAC. It is possible that in some patients the harms of NAC may outweigh the benefits. Trials Registry Number: NCT01335555.
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Affiliation(s)
- S Jack
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - M A West
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - D Raw
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - S Marwood
- Liverpool Hope University, Hope Park, Liverpool, United Kingdom.
| | - G Ambler
- Statistical Science, University College London, Torrington Place, London, United Kingdom.
| | - T M Cope
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - M Shrotri
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - R P Sturgess
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - P M A Calverley
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - C H Ottensmeier
- Cancer Sciences Division and Department of Medical Oncology, University Southampton NHS Foundation Trust, Southampton, United Kingdom; NIHR/CR-UK Experimental Cancer Medicine Centre, Southampton, United Kingdom.
| | - M P W Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Southampton NHS Foundation Trust, Southampton, United Kingdom.
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West MA, Lythgoe D, Barben CP, Noble L, Kemp GJ, Jack S, Grocott MPW. Cardiopulmonary exercise variables are associated with postoperative morbidity after major colonic surgery: a prospective blinded observational study. Br J Anaesth 2013; 112:665-71. [PMID: 24322573 DOI: 10.1093/bja/aet408] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Postoperative complications are associated with reduced fitness. Cardiopulmonary exercise testing (CPET) has been used in risk stratification. We investigated the relationship between preoperative CPET and in-hospital morbidity in major colonic surgery. METHODS We prospectively studied 198 patients undergoing major colonic surgery (excluding neoadjuvant cancer therapy), performing preoperative CPET (reported blind to clinical state), and recording morbidity (assessed blind to CPET), postoperative outcome, and length of stay. RESULTS Of 198 patients, 62 were excluded: 11 had emergency surgery, 25 had no surgery, 23 had incomplete data, and three were unable to perform CPET. One hundred and thirty-six (89 males, 47 females) were available for analysis. The median age was 71 [inter-quartile range (IQR) 62-77] yr. Sixty-five patients (48%) had a complication at day 5 after operation. Measurements significantly lower in patients with complications than those without were O2 uptake (VO₂) at estimated lactate threshold (θ(L)) [median 9.9 (IQR 8.3-12.7) vs 11.2 (9.5-14.2) ml kg(-1) min(-1), P<0.01], VO₂ at peak [15.2 (12.6-18.1) vs 17.2 (13.7-22.5) ml kg(-1) min(-1), P=0.01], and ventilatory equivalent for CO2 (V(E)/VCO₂) at θ(L) [31.3 (28.0-34.8) vs 33.9 (30.0-39.1), P<0.01]. A final multivariable logistic regression model contained VO₂ at θ(L) {one-point change odds ratio (OR) 0.77 [95% confidence interval (CI) 0.66-0.89], P<0.0005; two-point change OR 0.61 (0.46-0.81) and gender [OR 4.42 (1.78-9.88), P=0.001]}, and was reasonably able to discriminate those with and without complications (AUC 0.71, CI 0.62-0.80, 68% sensitivity, 65% specificity). CONCLUSIONS CPET variables are associated with postoperative morbidity. A multivariable model with VO₂ at θ(L) and gender discriminates those with complications after colonic surgery.
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Affiliation(s)
- M A West
- Colorectal Surgery Research Group, 3rd Floor Clinical Sciences Building, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool L9 7AL, UK
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Richter AW, Dawson JF, West MA. The effectiveness of teams in organizations: a meta-analysis. The International Journal of Human Resource Management 2011. [DOI: 10.1080/09585192.2011.573971] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Marusak RA, Guy JS, Abdul-Aziz TA, West MA, Fletcher OJ, Day JM, Zsak L, Barnes HJ. Parvovirus-associated cerebellar hypoplasia and hydrocephalus in day old broiler chickens. Avian Dis 2010; 54:156-60. [PMID: 20408417 DOI: 10.1637/8976-070709-case.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cerebellar hypoplasia and hydrocephalus were identified in day old broiler chickens showing nervous signs, impaired mobility, and diarrhea. At postmortem examination, brains of chickens were misshapen and cerebellums were smaller than normal. Microscopically, cerebellar folia were reduced in size and irregularly shaped, and the ventricles were widely distended. Affected cerebellums had focal areas along the base of folia where the internal granular cell layer had been lost, and Purkinje cells were disorganized and located within the molecular layer. Parvovirus DNA was detected by polymerase chain reaction in three of nine brains with oligonucleotide primers designed for amplification of chicken and turkey parvoviruses. On the basis of phylogenetic analyses, the detected virus was most closely related to chicken parvoviruses. These findings suggest that a chicken parvovirus might cause a neurologic disease of young chickens characterized by cerebellar hypoplasia and hydrocephalus; however, its role as the cause of the disease remains to be confirmed.
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Affiliation(s)
- R A Marusak
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 4700 Hillsborough Street, Raleigh, NC 27606, USA
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Abstract
Proteases perform two key roles in the class II MHC antigen processing pathway. They initiate removal of the invariant chain chaperone for class II MHC and they generate peptides from foreign and self proteins for eventual capture and display to T cells. How a balance is achieved between generation of suitable peptides versus their complete destruction in an aggressive proteolytic environment is not known. Nor is it known in most cases which proteases are actually involved in antigen processing. Our recent studies have identified asparagine endopeptidase (AEP or legumain) as an enzyme that contributes to both productive and destructive antigen processing in the class II MHC pathway. The emerging consensus seems to be that individual proteolytic enzymes make clear and non-redundant contributions to antigen processing.
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Affiliation(s)
- C Watts
- Division of Cell Biology Immunology, School of Life Sciences, University of Dundee, DD1 5EH, United Kingdom.
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Heagy W, Hansen C, Nieman K, Cohen M, Richardson C, Rodriguez JL, West MA. Impaired ex vivo lipopolysaccharide-stimulated whole blood tumour necrosis factor production may identify patients in the intensive care unit with ‘sepsis’ and multiple system organ failure. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2000.01544-39.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
There is currently no reliable diagnostic test to identify patients with sepsis in the intensive care unit (ICU) or patients with multiple system organ failure (MSOF). It was previously found that in vitro pretreatment of monocytes with lipopolysaccharide (LPS) induced blunted tumour necrosis factor (TNF) release to LPS rechallenge. It was hypothesized that patients exposed to LPS or septic stimuli in vivo would produce less TNF when stimulated ex vivo with LPS. This preliminary study sought to determine whether impaired ex vivo TNF release was associated with measurable differences in clinical outcome.
Methods
Heparinized whole blood was obtained from 27 ICU patients and five healthy controls, and incubated immediately with or without LPS 10 ng ml−1 at 37°C for 3 h, then centrifuged to recover serum. Serum TNF levels were measured using an enzyme-linked immunosorbent assay and expressed as mean(s.e.m.). Clinical data, such as ICU length of stay (LOS), duration of mechanical ventilation, white blood cell count and positive cultures, were obtained retrospectively. Quartiles (I, 0–25 per cent; II, 26–50 per cent; III, 51–75 per cent; and IV, 76–100 per cent) were identified on the basis of the distribution of plotted LPS-stimulated whole blood TNF values. Statistical analysis was by χ2 and Student's t tests.
Results
A wide range of LPS-stimulated whole blood TNF production was observed in ICU patients (5·1(0·7) ng ml−1) and controls (6·6(1·0) ng ml−1). Patients identified in the lowest quartile (n = 6) of TNF producers (less than 2 ng ml−1) had significantly lower TNF production and a higher incidence of infection (83 versus 38 per cent), and longer LOS (21·8 versus 9·0 days) and duration of mechanical ventilation (18·3 versus 6·0 days) than patients in quartiles II–IV (n = 21). Patients in the lowest quartile had significantly lower TNF production (1·1(0·2) ng ml−1) than normal controls (6·6(1·0) ng ml−1) (P < 0·05) or ICU patients in any other quartile (quartile II: 2·9(0·2) ng ml−1, quartile III: 5·3(0·3) ng ml−1, quartile IV: 10·4(1·3) ng ml−1) (P < 0·05).
Conclusion
The lowest levels of ex vivo LPS-stimulated whole blood TNF production were associated with a prolonged ICU stay, a higher incidence of positive cultures and a prolonged need for mechanical ventilation. Impaired TNF release may be a manifestation of monocyte endotoxin tolerance and may be a marker of monocytic dysfunction. Determination of whole blood ex vivo LPS-stimulated TNF production could be useful in the diagnosis of severe sepsis and MSOF in patients in the ICU.
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Affiliation(s)
- W Heagy
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - C Hansen
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - K Nieman
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - M Cohen
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - C Richardson
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - J L Rodriguez
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - M A West
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
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Kirkbright GF, Spillane DEM, Anthony K, Brown RG, Hepworth JD, Hodgson KW, West MA. Determination of the fluorescence quantum yields of some 2-substituted benzothiazoles. Anal Chem 2002. [DOI: 10.1021/ac00273a024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
This study integrates research on minority dissent and individual creativity, as well as team diversity and the quality of group decision making, with research on team participation in decision making. From these lines of research, it was proposed that minority dissent would predict innovation in teams but only when teams have high levels of participation in decision making. This hypothesis was tested in 2 studies, 1 involving a homogeneous sample of self-managed teams and 1 involving a heterogeneous sample of cross-functional teams. Study 1 suggested that a newly developed scale to measure minority dissent has discriminant validity. Both Study 1 and Study 2 showed more innovations under high rather than low levels of minority dissent but only when there was a high degree of participation in team decision making. It is concluded that minority dissent stimulates creativity and divergent thought, which, through participation, manifest as innovation.
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Affiliation(s)
- C K De Dreu
- Department of Psychology, University of Amsterdam, The Netherlands.
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Abstract
The current clinical management of surgical patients with sepsis is governed by two principles: control of the source of infection and supportive management of the patient until recovery. Recently, there has been renewed interest in the concept of source control-in particular, its importance for evaluating and comparing clinical trials. This brief review highlights some of the developments in the surgical literature. Important recent publications center on source control, the management of systemic inflammatory response syndrome, necrotizing pancreatitis, acute diverticulitis, gastrointestinal fistulas, and the role of laparoscopy in surgical infections. Novel interventions in supportive care are being developed, and their clinical applicability and effectiveness will be improved with increased understanding of the pathophysiology of systemic inflammation.
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Affiliation(s)
- D Danielson
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
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Abstract
BACKGROUND Nosocomial pneumonia (NP) in injured patients is a significant clinical problem. We hypothesize that the pathogenesis of NP in injured patients involves an imbalanced cytokine response within the alveolar airspace that may inhibit effector cell function. METHODS Proinflammatory (IL-8) and anti-inflammatory (IL-10) levels were measured in bronchoalveolar lavage (BAL) fluid from multitrauma patients on admission, 24, 48, and 72 hours post-injury and following lipopolysaccharide (LPS) induction of alveolar cells. Patients were compared based on IL-8 levels and the development of NP. RESULTS A high level of IL-8 on admission was associated with the development of NP. In addition, levels of IL-8 were significantly greater in NP-positive patients at all time points. The IL-10 levels decreased from admission values in NP-negative patients but increased in NP-positive patients. Furthermore, a high level of IL-10 ( > 120 pg/mL) at 72 hours post-injury was associated with the development of NP. Alveolar cells from NP-positive patients produced significantly more IL-10 in response to LPS than cells from NP-negative patients. CONCLUSIONS The pathogenesis of NP in injured patients involves an early and severe IL-8 process within the lung followed by an exaggerated IL-10 response that may inhibit effector cell function.
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Affiliation(s)
- S G Muehlstedt
- Department of Surgery, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis 55415, USA
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Rodriguez JL, Peterson DJ, Muehlstedt SG, Zera RT, West MA, Bubrick MP. The impact of managed care and current governmental policies on an urban academic health care center. Surgery 2001; 130:539-44; discussion 544-5. [PMID: 11602882 DOI: 10.1067/msy.2001.117103] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Managed care and governmental policies have restructured hospital reimbursement. We examined reimbursement trends in trauma care to assess the impact of this market driven change on an urban academic health center. METHODS Patients injured between January 1997 and December 1999 were analyzed for Injury Severity Score (ISS), length of hospital stay, hospital cost, payer, and reimbursement. RESULTS Between 1997 and 1999, the volume of patients with an ISS less than 9 increased and length of stay decreased. In addition, overall cost, payment, and profit margin increased. Commercially insured patients accounted for this margin increase, because the margins of managed care and government insured patients experienced double-digit decreases. Patients with ISS of 9 or greater also experienced a volume increase and a reduction in length of stay; however, costs within this group increased greater than payments, thereby reducing profit margin. Whereas commercially insured patients maintained their margin, managed care and government insured patients did not (double- and triple-digit decreases). CONCLUSIONS Managed care and current governmental policies have a negative impact on urban academic health center reimbursement. Commercial insurers subsidize not only the uninsured but also the government insured and managed care patients as well. National awareness of this issue and policy action are paramount to urban academic health centers and may also benefit commercial insurers.
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Affiliation(s)
- J L Rodriguez
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minn 55415, USA
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Abstract
The abdominal compartment syndrome is an increasingly recognized complication of both medical and surgical patients in the ICU setting. This syndrome has been described in a wide variety of clinical scenarios and results from a persistent elevation in intra-abdominal pressure characterized by graded organ system dysfunction. Manifestations of abdominal compartment syndrome include cardiovascular, pulmonary, renal, splanchnic, and neurologic impairment. The diagnosis of abdominal compartment syndrome requires a high level of clinical suspicion combined with an increased intra-abdominal pressure, usually obtained via urinary bladder pressure measurement. Patients at risk for abdominal compartment syndrome warrant close monitoring and we recommend prompt abdominal decompression following documentation of increased intra-abdominal pressure in the setting of physiologic compromise. Abdominal compartment syndrome can significantly contribute to the morbidity and mortality of both medical and surgical patients alike in the ICU. The signs and symptoms of abdominal compartment syndrome should become familiar to all critical care practitioners.
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Affiliation(s)
- J Morken
- Hennepin County Medical Center, University of Minnesota, 701 Park Avenue, Minneapolis, MN 55415, USA
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Wahlstrom K, Ney AL, Jacobson S, Odland MD, Van Camp JM, Rodriguez JL, West MA. Trauma in cirrhotics: survival and hospital sequelae in patients requiring abdominal exploration. Am Surg 2000; 66:1071-6. [PMID: 11090023] [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: 02/18/2023]
Abstract
Hepatic cirrhosis significantly increases the mortality and morbidity of elective surgery; therefore we hypothesized that cirrhosis would adversely impact outcome after abdominal trauma. We used the trauma registry to identify 17 patients with cirrhosis who sustained trauma injuries requiring emergent exploratory laparotomy. Patients were characterized with respect to age, sex, hospital days, intensive care unit days, and trauma scores. A control group (n = 73) was constructed from the registry by matching age, sex, Injury Severity Score (ISS) and Abbreviated Injury score. Mortality rates were compared by Fisher's exact test and age, ISS, Revised Trauma Score 2, and hospital and intensive care unit days were compared by Student's t test. Despite similar ISS between cirrhotic patients and controls, patients with cirrhosis had a fourfold increase in mortality (mortality odds ratio = 7.2; 95% confidence interval = 2.2-24.0). Cirrhotic trauma patients had a complication rate of 71 per cent and a mortality of 44 per cent. We conclude that cirrhosis is a major independent risk factor for mortality in trauma patients with injuries that require emergent abdominal surgery.
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Affiliation(s)
- K Wahlstrom
- Department of Surgery, Hennepin County Medical Center, University of Minnesota, Minneapolis, 55415, USA
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Heagy W, Hansen C, Nieman K, Rodriguez JL, West MA. Impaired mitogen-activated protein kinase activation and altered cytokine secretion in endotoxin-tolerant human monocytes. J Trauma 2000; 49:806-14. [PMID: 11086768 DOI: 10.1097/00005373-200011000-00003] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Dysregulation of monocyte/macrophage cytokine production after exposure to multiple inflammatory stimuli may contribute to multiple organ failure and sepsis. Endotoxin (lipopolysaccharide [LPS]) activation of murine macrophage results in the phosphorylation of kinases in the mitogen-activated protein kinase cascade. Pretreatment of murine macrophages with LPS induces LPS-tolerance, with inhibition of LPS-stimulated activation of kinases (ERK1/2 and p38) and diminished release of tumor necrosis factor (TNF). We sought to determine whether similar alterations in LPS-dependent signal transduction are present in LPS-tolerant human peripheral blood monocytes. METHODS Human peripheral blood monocytes from healthy volunteer donors (n = 12) were incubated in RPMI 1640 culture medium +/- 10 ng/mL of LPS for 18 hours, then stimulated with 0 to 1,000 ng/mL of LPS. Supernatant TNF and interleukin-1 (IL-1) levels were measured after 5 hours by enzyme-linked immunosorbent assay. Activation of the p42/p44 kinases (ERK1/2) was measured 15 minutes after LPS with monoclonal antibodies to diphosphorylated (active) ERK1/2 using novel flow cytometric methods. RESULTS LPS-tolerant (10 ng/mL LPS pretreatment) human monocytes had significant inhibition of LPS-stimulated TNF secretion but augmented IL-1 release (p < 0.05). Nontolerant human monocytes had a dramatic increase in the percentage of ERK1/2-positive cells in response to an initial stimulation with LPS. This did not occur in the LPS-tolerant cells. Phorbol-12-myristate-13 acetate restored ERK1/2 activation in LPS-tolerant human monocytes. CONCLUSION LPS-tolerance in human monocytes is associated with inhibition of LPS-stimulated TNF secretion, augmented release of IL-1, and defective activation of mitogen-activated protein kinase cascade (ERK1/2). These results suggest a method of identifying LPS-tolerance and monocyte dysfunction in patients with sepsis.
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Affiliation(s)
- W Heagy
- Department of Surgery, Hennepin County Medical Center, Minneapolis Medical Research Foundation, University of Minnesota 55415, USA
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Abstract
BACKGROUND The mission of public academic health centers (puAHC) and their affiliated practice groups (APG) focuses on teaching, research, and the clinical care of at-risk populations. Resources to accomplish this mission, however, are becoming scarce. For puAHC to survive and remain competitive, innovative strategies will need to be developed by the APG. We hypothesized that the integration of a surgical academic practice of the APG with a nonacademic integrated health care delivery system (NAIDS) in a managed care environment would benefit all involved. METHODS A surgical academic practice was integrated with a NAIDS in a 95% managed care market. Faculty alone provided care the first year, and third-year residents were added the following year. To assess outcome, we collected benefit and cost data for the 1-year period before integration and compared them with the two, 1-year periods after integration. RESULTS In the second year of integration, revenues from the NAIDS referrals to the puAHC and APG increased 89% and 150%, respectively. The NAIDS' general surgical and endoscopy caseload increased by 25%. Additionally, there was a 92% reduction in operating room technician cost with no increase in operating time per case. Finally, the third-year resident experienced a caseload increase of 163%. CONCLUSIONS In an environment where resources are diminishing and managed care consists of many large NAIDS that drive referrals and revenue, the integration of a surgical academic practice with a NAIDS benefits all shareholders. Academic practice groups that develop strategies that leverage their competitive advantage will have the best chance of surviving in today's turbulent health care market.
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Affiliation(s)
- J L Rodriguez
- Department of Surgery, Hennepin County Medical Center, Minn, USA
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Witzke JD, Kraatz JJ, Morken JM, Ney AL, West MA, Van Camp JM, Zera RT, Rodriguez JL. Stapled versus hand sewn anastomoses in patients with small bowel injury: a changing perspective. J Trauma 2000; 49:660-5; discussion 665-6. [PMID: 11038083 DOI: 10.1097/00005373-200010000-00013] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Recent studies indicate that trauma patients with hollow viscus injuries requiring anastomosis who are managed with stapling have a higher rate of complications than do those in whom a hand-sewn anastomosis is used. We undertook this study to determine whether this finding applied to patients with small bowel trauma at our institution. METHODS Records of patients with small bowel injuries were retrospectively reviewed. Demographics, severity of injury, injury management, and outcome data were collected. RESULTS Patients who had their small bowel injuries managed by hand-sewn repair versus resection and stapled anastomosis demonstrated a nonsignificant decrease in overall complication rate (35% vs. 44%) and rate of intra-abdominal complication (10% vs. 18%). Yet the rate of intra-abdominal abscess formation was significantly lower with hand-sewn repair than with resection and stapled anastomosis (4% vs. 13%). However, when hand-sewn primary repairs were excluded from the analysis and injuries that required resection and either stapled or hand-sewn anastomosis were compared, there was a similar overall complication rate (41% vs. 41%) and rate of intra-abdominal complications (17% vs. 21%). CONCLUSION The rate of intra-abdominal complications did not differ significantly between patients requiring small bowel resection and reanastomosis managed by either a stapled or hand-sewn technique. In our experience, surgical stapling devices appear to be safe for use in repairing traumatic small bowel injury.
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Affiliation(s)
- J D Witzke
- Department of Surgery, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis 55415, USA
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Abstract
BACKGROUND The mortality rate for abdominal vena caval injuries remains high. We examined the experience of a level I trauma center to determine factors significant to the outcome in these injuries. METHODS Forty-seven patients were identified in a retrospective review (1989 to 1999) of patients were identified with abdominal vena caval injury. Data were analyzed by uni- and multivariate methods, including logistic regression. RESULTS Most of the individuals with abdominal vena caval injuries were young male patients who were injured by penetrating trauma and who were hypotensive on arrival. The severity of injury and the number of organs injured was high. The overall mortality rate was 55%. Nonsurvivors were more often hypotensive in the field with physiologic derangement consistent with hemorrhagic shock. Type and location of injury as well as method of repair were associated with death. Multiple regression analysis revealed that prehospital initial systolic blood pressure and intraoperative bicarbonate levels were independent predictors of survival. CONCLUSIONS We identified factors related to poor outcome, including suprarenal and retrohepatic location of injury and variables that reflected the evolution of shock. Management should include appropriate resuscitation and ultimately may require novel operative techniques.
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Affiliation(s)
- C J Hansen
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minn. 55415, USA
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Heagy W, Hansen C, Nieman K, Cohen M, Richardson C, Rodriguez JL, West MA. Impaired ex vivo lipopolysaccharide-stimulated whole blood tumor necrosis factor production may identify "septic" intensive care unit patients. Shock 2000; 14:271-6; discussion 276-7. [PMID: 11028542 DOI: 10.1097/00024382-200014030-00005] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Currently, there is no reliable diagnostic test to identify septic intensive care unit (ICU) patients. We initiated studies to test the hypothesis that in sepsis, the in vivo exposure to endotoxin is detectable by the ex vivo analysis of lipopolysaccharide (LPS)-stimulated tumor necrosis factor (TNF) production. We obtained heparinized whole blood (WB) from 58 ICU patients and 14 healthy controls. The samples were incubated +/-10 ng/mL of LPS at 37 degrees C for 3 h. Plasma TNF levels were measured using enzyme-linked immunoassay (mean +/- standard error of the mean). Clinical data, including ICU length of stay (LOS), ventilator days (VentD), WBC, and positive cultures (Clt+), were obtained retrospectively. A wide range of LPS-stimulated WB TNF production (pg/mL) was observed in ICU patients (4481+/-469) and controls (6706+/-715). Patients were stratified into quartiles (I-IV) on the basis of the distribution of plotted LPS-stimulated TNF values (pg/mL). Patients in quartile I (N = 14) had significantly lower TNF production (< 2000 pg/mL, P < 0.05) and required increased VentD (16 vs. 10 days, P < 0.05) compared to quartiles II-IV (N = 44). Patients in quartile I also had a higher incidence of infection (79 vs. 50%) and longer LOS (18 vs. 13 d) compared to quartiles II-IV. Impaired TNF release may be a manifestation of monocyte endotoxin tolerance and may be useful to diagnose sepsis.
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Affiliation(s)
- W Heagy
- Department of Surgery, Hennepin County Medical Center, University of Minnesota, Minneapolis Medical Research Foundation, 55415, USA
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West MA, Clair L, Bellingham J, Wahlstrom K, Rodriguez JL. Defective lipopolysaccharide-dependent ERK 1/2 activation in endotoxin tolerant murine macrophages is reversed by direct protein kinase C stimulation. Shock 2000; 14:169-75. [PMID: 10947162 DOI: 10.1097/00024382-200014020-00016] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Lipopolysaccharide (LPSp) pretreatment inhibits TNF secretion in endotoxin-tolerant macrophages via alterations in signal transduction pathways of LPS activation (LPSa). Protein kinase C inhibitors prevent TNF release in response to LPSa and direct protein kinase C activation with phorbol myristate acetate (PMA) restores TNF secretion after LPSp. In the current experiments the effect of protein kinase C modulation on LPSa-stimulated ERK 1/2 activation was investigated. Murine macrophage TNF production was determined after stimulation with 100 ng/mL of LPSa, +/- 24 h pretreatment with 10 ng/mL of LPSp. Direct protein kinase C activators (PMA or indolactam) or inhibitors (H7 or bisindolylmaleimide) were added 1 h before LPSa. Diphosphorylated ERK 1/2 was assayed after LPSa stimulation by Western blot. LPS tolerance after LPSp was characterized by inhibition of LPSa-stimulated TNF and accompanied by impaired ERK 1/2 activation by LPSa. Protein kinase C activation with PMA or indolactam restored ERK 1/2 activation and TNF secretion. Inhibition of protein kinase C with H7 or bisindolylmaleimide prevented TNF secretion and ERK 1/2 activation by LPSa. These findings suggest that both ERK 1/2 and protein kinase C are required for TNF production in nontolerant macrophages and that LPS tolerance may be associated with an inability to phosphorylate ERK 1/2.
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Affiliation(s)
- M A West
- Department of Surgery, Hennepin County Medical Center, University of Minnesota, Minneapolis 55415, USA
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West MA, Clair L, Kraatz J, Rodriguez JL. Endotoxin tolerance from lipopolysaccharide pretreatment induces nuclear factor-kappaB alterations not present in C3H/HeJ mice. J Trauma 2000; 49:298-305. [PMID: 10963543 DOI: 10.1097/00005373-200008000-00018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lipopolysaccharide (LPS) activation of macrophage (MO) cytokine secretion requires activation and translocation of nuclear factor-kappaB (NF-kappaB). Endotoxin tolerance induced in LPS-responsive C3H/HeN MOs by LPS pretreatment results in decreased tumor necrosis factor (TNF) secretion and altered NF-kappaB activation. C3H/HeJ MOs have a genetic defect that renders them tolerant to LPS activation. We hypothesized that the alterations of NF-kappaB activation seen with LPS tolerance in HeN MOs would be present in HeJ mice. METHODS MOs from C3H/HeJ and C3H/HeN mice were cultured with +/- 10 ng/mL LPS pretreatment for 24 hours and then stimulated with 1 to 1,000 ng/mL LPS. Activation of NF-kappaB was assayed by gel shift using a 32P-labeled specific oligonucleotide 30 minutes after LPS activation. TNF secretion 6 hours after LPS stimulation was measured by bioassay. RESULTS LPS stimulation activated NF-kappaB in both HeN and HeJ MOs. We observed decreased NF-kappaB activation and a characteristic mobility shift in endotoxin-tolerant MOs from HeN mice that were not present in HeJ MOs. In contrast with the results in HeN mice, LPS pretreatment did not induce any alterations in NF-kappaB activation in HeJ MOs. LPS-stimulated TNF secretion was decreased in HeN MOs after LPS pretreatment. There was no change in TNF secretion in HeJ MOs, but, overall, TNF secretion by these cells was much less than that seen in HeN cells. CONCLUSION MOs from C3H/HeN mice rendered LPS-tolerant by low-dose LPS pretreatment have alterations in activation of NF-kappaB not present in LPS-hyporesponsive C3H/HeJ mice.
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Affiliation(s)
- M A West
- Department of Surgery, Hennepin County Medical Center, University of Minnesota, Minnepaolis 55415, USA.
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West MA, Prescott AR, Eskelinen EL, Ridley AJ, Watts C. Rac is required for constitutive macropinocytosis by dendritic cells but does not control its downregulation. Curr Biol 2000; 10:839-48. [PMID: 10899002 DOI: 10.1016/s0960-9822(00)00595-9] [Citation(s) in RCA: 221] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Dendritic cells use constitutive macropinocytosis to capture exogenous antigens for presentation on MHC molecules. Upon exposure to inflammatory stimuli or bacterial products such as lipopolysaccharide (LPS), macropinocytosis is dramatically downregulated as part of a developmental programme leading to dendritic cell maturation, migration and activation of T cells. It is not known, however, how macropinocytosis is sustained in dendritic cells in the absence of exogenous stimuli, nor how it is downregulated upon maturation. We have tested the possibility that one or more members of the Rho family of GTPases are involved in and control pinocytosis in dendritic cells. RESULTS We established dendritic cell populations that show constitutive macropinocytosis that was downregulated by LPS treatment. Microinjection of immature cells with dominant-negative Rac (N17Rac1) or treatment with Clostridium difficile toxin B, the phosphoinositide 3-kinase (PI3-K) inhibitor wortmannin, or LPS all inhibited the formation of macropinosomes but, surprisingly, did not eliminate membrane ruffling. Microinjection of N17Cdc42 or the Rho inhibitor C3 transferase eliminated actin plaques/podosomes and actin cables, respectively, but had little effect on the formation of macropinosomes. Surprisingly, dendritic cells matured with LPS had equivalent or even somewhat higher levels of active Rac than immature cells. Moreover, microinjection of a constitutively active form of Rac (V12Rac1) into mature dendritic cells did not reactivate macropinocytosis. CONCLUSIONS Rac has an important role in the constitutive formation of macropinosomes in dendritic cells but may be required downstream of membrane ruffling. Furthermore, regulation of Rac activity does not appear to be the control point in the physiological downregulation of dendritic cell pinocytosis. Instead, one or more downstream effectors may be modulated to allow Rac to continue to regulate other cellular functions.
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Affiliation(s)
- M A West
- Department of Biochemistry, MSI/WTB Complex, University of Dundee, Dundee, DDI 5EH, UK.
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Abstract
Previous studies have shown that mice lacking the actin-severing and capping protein gelsolin have defects in leukocyte and platelet function. Moreover, dermal fibroblasts from gelsolin knockout (Gsn(-)) mice showed substantially reduced motility, membrane ruffling and pinocytosis. We have generated dendritic cells (DC) from spleens of Gsn(-) mice to investigate the importance of gelsolin in antigen endocytosis and processing. We show here that Gsn(-) DC produce apparently normal membrane ruffles which can resolve to form large macropinosomes. Moreover, presentation of exogenous antigens on both MHC class II and class I molecules was equivalent in Gsn(-) and wild-type DC. Thus the major rearrangements of the actin cytoskeleton needed for DC antigen uptake and presentation can proceed in the absence of a major actin filament regulatory protein.
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Affiliation(s)
- M A West
- Department of Biochemistry, University of Dundee, Dundee, GB
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Morken JJ, Kraatz JJ, Balcos EG, Hill MJ, Ney AL, West MA, Van Camp JM, Zera RT, Jacobs DM, Odland MD, Rodriguez JL. Civilian rectal trauma: a changing perspective. Surgery 1999; 126:693-8; discussion 698-700. [PMID: 10520917] [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: 02/14/2023]
Abstract
BACKGROUND Recently the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma developed a Rectal Injury Scaling System (RISS). Little data exist regarding its clinical utility. METHODS We retrospectively reviewed 45 patients with rectal injuries to assess the impact of the RISS on patient management and outcome. We compared RISS grade I patients (group I, partial-thickness injury) with patients with grades 2, 3, and 4 injuries (group II, full-thickness injury). RESULTS Group II underwent distal rectal washout and repair of the injury twice as often and had a significantly higher rate of diversion of the fecal stream. This was associated with a 3-fold increase in complications. The only complications in group I were in patients managed with diversion of the fecal stream and distal rectal washout. CONCLUSIONS Our data suggest that aggressive surgical management for RISS grade I injury may not be necessary. Implementation of therapy based on the RISS may improve outcomes of civilian rectal trauma.
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Affiliation(s)
- J J Morken
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minn 55415, USA
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Khetarpal S, Steinbrunn BS, McGonigal MD, Stafford R, Ney AL, Kalb DC, West MA, Rodriguez JL. Trauma faculty and trauma team activation: impact on trauma system function and patient outcome. J Trauma 1999; 47:576-81. [PMID: 10498319 DOI: 10.1097/00005373-199909000-00028] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the impact of the presence of an attending trauma surgeon during trauma team activation on system function and patient outcome. METHODS After a retrospective review of medical records and trauma registry, a comparative study between two American College of Surgeons Committee on Trauma Level I trauma centers was performed. One center (Hennepin County Medical Center) required a chief surgical resident, two junior residents, and a board-certified emergency medicine faculty to be present in the emergency department for all trauma team activations. The attending trauma surgeon was notified at the time of trauma team activation and was neither required to be present in the emergency department at time of patient arrival nor in the hospital 24 h/day. The other center (St. Paul Ramsey Medical Center) required a chief surgical resident, two junior residents, a board-certified emergency medicine faculty member, and an attending trauma surgeon to be present in the emergency department for all trauma activations and in hospital 24 hours/day. Over a 21-month period, all major trauma patients (Injury Severity Score > 15 or emergent operation within 4 hours of admission and any Injury Severity Score) that triggered trauma team activation were examined. Resuscitation time, time to incision, probability of survival, and mortality were analyzed. RESULTS Resuscitation time was shorter at St. Paul Ramsey Medical Center when compared with Hennepin County Medical Center. Analysis by mechanism of injury demonstrates that this was true for blunt trauma (39+/-13 vs. 27+/-12 minutes, p = 0.001) and for penetrating trauma (28+/-14 vs. 24+/-17 minutes, p = 0.01). Subgroup analysis of penetrating trauma victims demonstrated that there was a significant difference in resuscitation times for gunshot wounds but not for stabs. There was no difference in how quickly operations could be initiated for blunt trauma patients. However, in penetrating cases, time to incision was significantly shorter at St. Paul Ramsey Medical Center (50+/-29 vs. 66+/-43 minutes, p = 0.01). There was no significant difference in mortality for any category of Trauma and Injury Severity Score probability of survival in blunt or penetrating trauma. Analysis of "in-house" and "out-house" time intervals demonstrated no difference in survival in any mechanism of injury, nor was there a difference in overall mortality. CONCLUSION The presence of a trauma surgeon on the trauma team reduced resuscitation time and reduced time to incision for emergent operations, particularly in penetrating trauma. However, it had no measurable impact on mortality based on Trauma and Injury Severity Score probability of survival. Attending trauma surgeon presence on the trauma team improves in-hospital trauma system function without affecting patient outcome.
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Affiliation(s)
- S Khetarpal
- Department of Surgery, St. Paul Ramsey Medical Center, University of Minnesota, St. Paul, USA
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Abstract
PURPOSE Endotoxin (LPS) activation of macrophages results in phosphorylation of mitogen-activated protein kinases (MAPK), stress-activated protein kinases (SAPK), and p38 kinase. LPS pretreatment inhibits subsequent LPS-stimulated MAPK activation and TNF release and both were reversed if macrophages were treated with phorbol myristate acetate (PMA) before LPS stimulation. In this study we sought to determine if SAPK and p38 tyrosine kinases are required for TNF production and if LPS pretreatment alters their activation. METHODS TNF production by murine peritoneal exudate macrophages was determined 6 h after stimulation with 100 ng/mL of LPS +/- 24 h pretreatment with 10 ng/mL of LPS. The active, diphosphorylated forms of MAPK (p42, p44), SAPK (p46, p54), and p38 were assayed 30 min after LPS stimulation by Western immunoblot using specific antibodies. In some experiments a p38 kinase inhibitor (SB202190) or the protein kinase C activator (PMA) was added 1 h before LPS stimulation. RESULTS LPS activated MAPK, SAPK, and p38. LPS pretreatment significantly inhibited MAPK, SAPK, and p38 activation by LPS stimulation. TNF protein secretion and MAPK activation in tolerant macrophages were restored by PMA treatment, but this did not restore SAPK activation. The p38 inhibitor SB202190 blocked LPS-stimulated TNF production. CONCLUSION LPS pretreatment-induced tolerance decreased LPS-stimulated MAP, SAP, and p38 kinase activation. LPS tolerance in murine macrophages appears to be associated with specific, PMA-reversible defects in MAPK and p38 kinase activation.
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Affiliation(s)
- J Kraatz
- Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota 55415, USA
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Lemieur TP, Rodriguez JL, Jacobs DM, Bennett ME, West MA. Wound management in perforated appendicitis. Am Surg 1999; 65:439-43. [PMID: 10231213] [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: 02/12/2023]
Abstract
Open wound management after perforated appendicitis was common practice but, recently, primary closure has been advocated to reduce costs and morbidity. Hospital records from 319 adults who underwent appendectomy from 1993 to 1996 were reviewed to identify surgical wound infections (SWIs) and examine risk factors. Information about age, length of stay (LOS), operative time, white blood cell count, and antibiotic administration were obtained. Perforation was either noted at operation or identified microscopically by the pathologist. If primary wound closure was performed, patients with acute appendicitis and perforation had a 4-fold higher readmission rate, a 5-fold increase in SWI, and twice the LOS compared with patients with acute appendicitis without perforation. Patients with grossly perforated acute appendicitis had no difference in LOS if the wound was treated open or closed primarily. No patient with microscopic perforation and primary wound closure developed SWI. Primary wound closure after acute appendicitis was safe in the absence of clinical perforation. In the presence of clinical appendiceal perforation the wound should be left open.
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Affiliation(s)
- T P Lemieur
- Department of Surgery, Hennepin County Medical Center, University of Minnesota, Minneapolis, USA
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Abstract
The transcription factor nuclear factor (NF)-kappaB is thought to be required for endotoxin-stimulated tumor necrosis factor (TNF) and interleukin (IL)-1 gene transcription. Nuclear translocation of NF-kappaB is regulated by the cytoplasmic inhibitory factor IkappaBalpha. Low-dose lipopolysaccharide (LPS) pretreatment modulates cytokine release by altering subsequent LPS-activated signal transduction pathways. In this study, we examined the effect of LPS pretreatment exposure on IkappaBalpha and NF-kappaB following activation with LPS. Murine macrophages (Mphi were exposed to a range of LPS concentrations +/-24 h PreRx with 10 ng/mL LPS pretreatment. Cytoplasmic IkappaBalpha (Western immunoblot) and NF-kappaB (gel-shift assay) were assayed 30 min after LPS activation. Gene transcription for TNF was measured 6 h after LPS activation using RT-PCR. In the absence of LPS pretreatment, IkappaBalpha disappeared from the cytoplasm coincident with nuclear translocation of NF-kappaB. Tolerant Mphi had markedly enhanced levels of IkappaBalpha and normal to increased levels of NF-kappaB translocation with a different electrophoretic shift. LPS activation enhanced cytokine gene transcription in a dose-dependent manner, and this was unaltered by LPS pretreatment. Endotoxin-tolerant Mphi also had increased cytoplasmic levels of the p65 subunit of NF-kappaB. LPS tolerance is associated with increases of cytoplasmic IkappaBalpha p65, as well as enhanced NF-kappaB. We conclude that control of NF-kappaB translocation by IkappaBalpha is dysregulated in endotoxin-tolerant Mphi.
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Affiliation(s)
- K Wahlstrom
- Department of Surgery, Hennepin County Medical Center, University of Minnesota, Minneapolis 55415, USA
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Kraatz J, Clair L, Rodriguez JL, West MA. In vitro macrophage endotoxin tolerance: defective in vitro macrophage map kinase signal transduction after LPS pretreatment is not present in macrophages from C3H/HeJ endotoxin resistant mice. Shock 1999; 11:58-63. [PMID: 9921718 DOI: 10.1097/00024382-199901000-00009] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Altered endotoxin (LPS) signal transduction in macrophages (Mphi) may mediate development of organ dysfunction in sepsis. C3H/HeJ Mphi have a specific genetic defect that renders them "tolerant" to in vitro LPS activation. LPS tolerance can be induced in normal C3H/HeN Mphi following in vitro LPS pretreatment. In these experiments, in vitro LPS-stimulated activation of Mphi mitogen-activated protein (MAP) kinases were compared in C3H/HeJ and C3H/HeN mice. C3H/HeJ and C3H/HeN Mphi were cultured+/-10 ng/mL LPS pretreatment for 24 h, then stimulated with 0-1,000 ng/mL LPS for 6 h. Western blots were performed on lysates with monoclonal antibody to active ERK1,2 (p42/44), stress-activated protein kinase (SAPK, p54/46), and p38 kinase. Supernatant TNF or IL-1 was determined by bioassay. High dose LPS stimulation activated ERK, SAPK, and p38 kinases in both C3H/HeN and C3H/HeJ Mphi. ERK activation, p46 SAPK, and p38 activation were inhibited in C3H/HeN Mphi after LPS pretreatment, whereas they were unchanged or increased in HeJ Mphi. TNF secretion was significantly decreased in C3H/HeN Mphi following LPS pretreatment, but absent in C3H/HeJ Mphi at all times. Mphi from normal C3H/HeN mice rendered endotoxin tolerant by in vitro, low dose LPS pretreatment have specific signal transduction defects that are not present in genetically LPS hyporesponsive C3H/HeJ mice.
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Affiliation(s)
- J Kraatz
- Department of Surgery, Hennepin County Medical Center University of Minnesota, Minneapolis 55415, USA
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