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Edgar JDM, Buckland M, Guzman D, Conlon NP, Knerr V, Bangs C, Reiser V, Panahloo Z, Workman S, Slatter M, Gennery AR, Davies EG, Allwood Z, Arkwright PD, Helbert M, Longhurst HJ, Grigoriadou S, Devlin LA, Huissoon A, Krishna MT, Hackett S, Kumararatne DS, Condliffe AM, Baxendale H, Henderson K, Bethune C, Symons C, Wood P, Ford K, Patel S, Jain R, Jolles S, El-Shanawany T, Alachkar H, Herwadkar A, Sargur R, Shrimpton A, Hayman G, Abuzakouk M, Spickett G, Darroch CJ, Paulus S, Marshall SE, McDermott EM, Heath PT, Herriot R, Noorani S, Turner M, Khan S, Grimbacher B. The United Kingdom Primary Immune Deficiency (UKPID) Registry: report of the first 4 years' activity 2008-2012. Clin Exp Immunol 2014; 175:68-78. [PMID: 23841717 PMCID: PMC3898556 DOI: 10.1111/cei.12172] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2013] [Indexed: 12/11/2022] Open
Abstract
This report summarizes the establishment of the first national online registry of primary immune deficency in the United Kingdom, the United Kingdom Primary Immunodeficiency (UKPID Registry). This UKPID Registry is based on the European Society for Immune Deficiency (ESID) registry platform, hosted on servers at the Royal Free site of University College, London. It is accessible to users through the website of the United Kingdom Primary Immunodeficiency Network (www.ukpin.org.uk). Twenty-seven centres in the United Kingdom are actively contributing data, with an additional nine centres completing their ethical and governance approvals to participate. This indicates that 36 of 38 (95%) of recognized centres in the United Kingdom have engaged with this project. To date, 2229 patients have been enrolled, with a notable increasing rate of recruitment in the past 12 months. Data are presented on the range of diagnoses recorded, estimated minimum disease prevalence, geographical distribution of patients across the United Kingdom, age at presentation, diagnostic delay, treatment modalities used and evidence of their monitoring and effectiveness.
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Affiliation(s)
- J D M Edgar
- Regional Immunology Service, The Royal Hospitals, Belfast, East Yorkshire; Centre for Infection and Immunity, Queen's University Belfast, Belfast, East Yorkshire
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Chitkara R, Batchelor H, Sapsford RJ, Workman S, Patel ARC, Mackay AJ, Grimbacher B, Hurst JR. P246 Airway and systemic inflammation in stable and exacerbated bronchiectasis: a pilot study. Thorax 2011. [DOI: 10.1136/thoraxjnl-2011-201054c.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Martini H, Enright V, Perro M, Workman S, Birmelin J, Giorda E, Quinti I, Lougaris V, Baronio M, Warnatz K, Grimbacher B. Importance of B cell co-stimulation in CD4(+) T cell differentiation: X-linked agammaglobulinaemia, a human model. Clin Exp Immunol 2011; 164:381-7. [PMID: 21488866 DOI: 10.1111/j.1365-2249.2011.04377.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
We were interested in the question of whether the congenital lack of B cells actually had any influence on the development of the T cell compartment in patients with agammaglobulinaemia. Sixteen patients with X-linked agammaglobulinaemia (XLA) due to mutations in Btk, nine patients affected by common variable immune deficiency (CVID) with <2% of peripheral B cells and 20 healthy volunteers were enrolled. The T cell phenotype was determined with FACSCalibur and CellQuest Pro software. Mann-Whitney two-tailed analysis was used for statistical analysis. The CD4 T cell memory compartment was reduced in patients with XLA of all ages. This T cell subset encompasses both CD4(+)CD45RO(+) and CD4(+)CD45RO(+)CXCR5(+) cells and both subsets were decreased significantly when compared to healthy controls: P = 0·001 and P < 0·0001, respectively. This observation was confirmed in patients with CVID who had <2% B cells, suggesting that not the lack of Bruton's tyrosine kinase but the lack of B cells is most probably the cause of the impaired CD4 T cell maturation. We postulate that this defect is a correlate of the observed paucity of germinal centres in XLA. Our results support the importance of the interplay between B and T cells in the germinal centre for the activation of CD4 T cells in humans.
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Affiliation(s)
- H Martini
- Department of Immunology, Royal Free Hospital and University College London, UK
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Workman S. Death rarely desired, anywhere. West J Med 2009. [DOI: 10.1136/bmj.b3265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
Multiple studies have demonstrated that treatment at or near the end of life is rarely optimal. Unwanted death-prolonging treatments are frequently provided and open communication about death and dying is often lacking. Early effective communication about goals, prognosis and options would improve patient care at or near the end of life by enhancing choice and facilitating palliative care. A five-step sequential approach to communicating with patients at risk of dying in hospital about treatment goals and outcomes (and/or their family members) is presented. The five steps are founded upon the recognition that trials of life-sustaining treatments are also, by definition, trials of palliative care. A narrative review of currently available qualitative and quantitative research is used to support the recommendations.
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Affiliation(s)
- S Workman
- Bethune Building, QEII HSC, Halifax, Nova Scotia, Canada.
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Chua I, Standish R, Lear S, Harbord M, Eren E, Raeiszadeh M, Workman S, Webster D. Anti-tumour necrosis factor-alpha therapy for severe enteropathy in patients with common variable immunodeficiency (CVID). Clin Exp Immunol 2007; 150:306-11. [PMID: 17822445 PMCID: PMC2219360 DOI: 10.1111/j.1365-2249.2007.03481.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [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: 01/21/2023] Open
Abstract
We present three common variable immunodeficiency (CVID) patients with severe inflammatory bowel disease of unknown aetiology, resistant to steroid treatment, treated with infliximab. After exclusion of any infection, infliximab was given at a dose of 5 mg/kg every 4 weeks for a 3 month induction followed by every 4-8 weeks depending on clinical response. Two of these patients had predominantly small bowel disease; they both showed clinical response to infliximab with weight gain and improvement of quality of life scores. The third patient had large bowel involvement with profuse watery diarrhea; this patient improved dramatically within 48 hours of having infliximab treatment. All three patients have been maintained on infliximab treatment for between 5 and 53 months (mean 37 months) with no evidence of increased susceptibility to infections in the patients with small bowel disease, although the third patient developed two urinary tract infections and a herpes zoster infection following therapy. This is the first small case series to show that infliximab is a useful addition to current therapy in this rare group of patients with potentially life threatening enteritis.
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Affiliation(s)
- I Chua
- Department of Immunology, Royal Free Hospital Hampstead, London, UK.
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Abstract
BACKGROUND In our institution, about one third of annual deaths occur on the general medical teaching unit. (MTU) The average patient dies on the MTU from non-malignant disease after 4 weeks in hospital, and approximately 20% of available beds on the MTU at any time are occupied by patients who will not survive to discharge, but quality of end-of-life care on the MTU is not routinely assessed. AIM To identify areas for improvement in delivering high quality end-of-life care on the medical teaching unit. DESIGN Qualitative study using semi-structured interviews. METHODS Six months after the death of the patient, next of kin were sent a letter inviting participation; 75 family members were screened and 50 invitations were mailed out. Interviews were conducted in the home. Eliciting narratives and direct questioning about important aspects of end-of-life care were used. RESULTS Six next of kin agreed to participate. All patients were described as seriously and chronically ill. None died of cancer. Deaths were not described as 'good', and some comments suggested that death was unexpected and not inevitable. There were few concerns about pain control or unnecessary suffering. Proactive efforts to provide prognostic information or end-of-life care were not described. Survival, not palliation, was of central importance. Consistent with this priority, satisfaction with care provided in the intensive care unit was high. Follow-up after death was desired, especially if autopsy results were available. DISCUSSION Earlier discussions about treatment failure and end-of-life care, and the need for palliation, appear to be central to improving the quality of end-of-life care for patients dying on our medical teaching unit. Our results are consistent with other studies in this area.
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Affiliation(s)
- S Workman
- Division of General Internal Medicine, QEII Health Science Centre, Halifax, Nova Scotia, Canada.
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Workman S. The limits of hope. CMAJ 2007. [DOI: 10.1503/cmaj.061431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Raeiszadeh M, Kopycinski J, Paston SJ, Diss T, Lowdell M, Hardy GAD, Hislop AD, Workman S, Dodi A, Emery V, Webster AD. The T cell response to persistent herpes virus infections in common variable immunodeficiency. Clin Exp Immunol 2007; 146:234-42. [PMID: 17034575 PMCID: PMC1942048 DOI: 10.1111/j.1365-2249.2006.03209.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
We show that at least half of patients with common variable immunodeficiency (CVID) have circulating CD8(+) T cells specific for epitopes derived from cytomegalovirus (CMV) and/or the Epstein-Barr virus (EBV). Compared to healthy age-matched subjects, more CD8(+) T cells in CVID patients were committed to CMV. Despite previous reports of defects in antigen presentation and cellular immunity in CVID, specific CD4(+) and CD8(+) T cells produced interferon (IFN)-gamma after stimulation with CMV peptides, and peripheral blood mononuclear cells secreted perforin in response to these antigens. In CVID patients we found an association between a high percentage of circulating CD8(+) CD57(+) T cells containing perforin, CMV infection and a low CD4/CD8 ratio, suggesting that CMV may have a major role in the T cell abnormalities described previously in this disease. We also show preliminary evidence that CMV contributes to the previously unexplained severe enteropathy that occurs in about 5% of patients.
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Affiliation(s)
- M Raeiszadeh
- Centre for Immunology, Hampstead Campus, Royal Free and University College Medical School, London, UK
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Abstract
Monocyte-derived dendritic cells (MdDCs) from many patients with common variable immunodeficiency (CVID) have been shown recently to have reduced expression of surface molecules associated with maturity. Using flow cytometry and confocal microscopy, we now show that this is due to a partial failure to fix Class II DR molecules on the surface during procedures that induce full maturation in vitro in cells from normal subjects. Major histocompatibility complex (MHC) class I, CD86 and CD83 expression were expressed normally, but CD40 was reduced. These abnormalities are unlikely to be due to prior in vivo exposure of monocytes to lipopolysaccharide (LPS), as addition of LPS to monocytes from normal subjects in vitro caused a different pattern of changes. CVID MdDCs retained Class II DR in the cytoplasm during maturation, showed increased internalization of cross-linked Class II DR surface molecules and were unable to polarize DR within a lipid raft at contact sites with autologous lymphocytes. These cells retained some features of monocytes, such as the ability to phagocytose large numbers of fixed yeast and fluorescent carboxylated microspheres and expression of surface CD14. These abnormalities, if reflected in vivo, could compromise antigen presentation and may be a fundamental defect in the mechanism of the antibody deficiency in a substantial subset of CVID patients.
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Affiliation(s)
- T H Scott-Taylor
- Department of Immunology, Royal Free and University College Medical School, London, UK
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Workman S. Cardiopulmonary resuscitation: charting a course for the future. QJM 2006; 99:711-5. [PMID: 16998211 DOI: 10.1093/qjmed/hcl097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S Workman
- Department of Medicine, Division of General Internal Medicine, Dalhousie University, Halifax, Canada.
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Linstadt DE, Logsdon M, Stickney D, Chabra D, Russo M, Workman S. Permanent 125I prostate brachytherapy outcome in patients younger than 60. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.14553] [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] Open
Abstract
14553 Background: Permanent 125I prostate brachytherapy (PB) has been shown to be an effective form of treatment for men with clinically localized prostate cancer. However, the efficacy of PB in younger men is not well established, and many urologists and oncologists have been reluctant to recommend PB to younger men, since most reported PB outcome has been based on men implanted in their late 60s and 70s. Methods: Between 1/1/98 and 6/30/01, 100 consecutive men aged 49–59 (median 56) underwent PB. All had either low- or intermediate-risk disease. PB was performed without combined external beam irradiation or post-PB androgen deprivation. The prescribed radiation dose=144–145Gy, the median implant activity=38mCi, median prostate volume=36 ml. Mean day-30 post-PB CT-based implant dosimetry values were V100=94%; V150=60%; D90=160 Gy. The primary endpoint for this analysis was the 5-year biochemical no evidence of disease rate (bNED) defined by the ASTRO consensus definition. Secondary endpoints were disease-specific survival (DSS); freedom from salvage therapy (FSRx), and overall survival (OS). Median PSA followup was 59 months (maximum 93 months). Actuarial results were calculated using the Kaplan-Meier method. Results: The 5-year bNED rate was 92%. 8 patients developed biochemical failure, and 6 went on to salvage treatment with hormonal therapy. There were 2 biopsy-proven local recurrences: one in a patient with previously diagnosed bony metastases, and one with isolated seminal vesicle recurrence (prostate biopsies negative). 3 other patients with biochemical failure had negative re-biopsies at 24, 64, and 66 months post-PB. No patient received local salvage therapy. One patient died from a second malignancy (colon CA diagnosed after PB). The 5-year DSS rate = 100%; FSRx = 93%, and OS = 99%. There were 2 Grade 3 GU complications (urethral strictures) (2%) and one Grade 4 GU complication (TURP) (1%). There were no Grade 3 or 4 GI complications. Conclusions: PB is an effective treatment modality for men younger than 60, with 5 year results comparable to those reported with prostatectomy and external beam irradiation. Given that most men who fail PB do so within 5 years of the implant, there appears to be no compelling scientific reason to advise against PB in men younger than 60 solely based on their age. No significant financial relationships to disclose.
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Affiliation(s)
| | - M. Logsdon
- RASMG, Roseville, CA; TPMG, Roseville, CA
| | | | - D. Chabra
- RASMG, Roseville, CA; TPMG, Roseville, CA
| | - M. Russo
- RASMG, Roseville, CA; TPMG, Roseville, CA
| | - S. Workman
- RASMG, Roseville, CA; TPMG, Roseville, CA
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Workman S. A week of rain, a gust of wind: narrative ethics and the teachable moment. CMAJ 2006. [DOI: 10.1503/cmaj.060087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Linstadt D, Logsdon M, Pu T, Workman S, Chabra D, Russo M, Goldman L, Stickney D. Comparison of the ASTRO Consensus Definition Versus the Houston/Current PSA Nadir + 2 Definition of Biochemical Failure in Prostate Cancer Patients Undergoing Permanent Iodine-125 Brachytherapy. Int J Radiat Oncol Biol Phys 2005. [DOI: 10.1016/j.ijrobp.2005.07.528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mahmoudieh A, Goldman L, Russo M, Chabra D, Workman S, Lindstat D. Intraoperative Prostate Brachytherapy: Does Real-Time Ultrasound-Based Dosimetry Obviate the Need for Post Implant Dosimetric Analysis? A Retrospective Analysis of 1100 Patients Treated at Kaiser Permanente of Northern California. Int J Radiat Oncol Biol Phys 2005. [DOI: 10.1016/j.ijrobp.2005.07.552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Linstadt DE, Stickney D, Logsdon M, Workman S, Chabra D, Russo M, Goldman L. Permanent prostate brachytherapy: Outcome in the community/HMO setting. J Clin Oncol 2005. [DOI: 10.1200/jco.2005.23.16_suppl.4707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- D. E. Linstadt
- Radiological Assoc of Sacramento, Roseville, CA; Kaiser Permanente Medcl Group, Sacramento, CA
| | - D. Stickney
- Radiological Assoc of Sacramento, Roseville, CA; Kaiser Permanente Medcl Group, Sacramento, CA
| | - M. Logsdon
- Radiological Assoc of Sacramento, Roseville, CA; Kaiser Permanente Medcl Group, Sacramento, CA
| | - S. Workman
- Radiological Assoc of Sacramento, Roseville, CA; Kaiser Permanente Medcl Group, Sacramento, CA
| | - D. Chabra
- Radiological Assoc of Sacramento, Roseville, CA; Kaiser Permanente Medcl Group, Sacramento, CA
| | - M. Russo
- Radiological Assoc of Sacramento, Roseville, CA; Kaiser Permanente Medcl Group, Sacramento, CA
| | - L. Goldman
- Radiological Assoc of Sacramento, Roseville, CA; Kaiser Permanente Medcl Group, Sacramento, CA
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Abstract
The electrochemical and electrochemiluminescence (ECL) properties of Cu[dmp]2+ (dmp = 2,9-dimethyl-1,10-phenanthroline) have been investigated. ECL has been observed for Cu(dmp)2+ in aqueous, nonaqueous, and mixed solvent solutions using tri-n-propylamine as an oxidative-reductive coreactant. The ECL intensity peaks at potential corresponding to oxidation of both the coreactant and Cu(dmp)2+. The peak potential corresponding to maximum ECL emission is approximately 500 mV more anodic than corresponding oxidative peak potentials, indicating that the ECL emission may be due to the formation of either the *Cu(dmp)2+ metal-to-ligand charge-transfer excited state or an excited-state product of Cu(dmp)2+ oxidation. ECL efficiencies (phiecl = photons generated per redox event) are solvent-dependent (phiecl (CH3CN) > phiecl (50:50 (v/v) CH3CN:H20) > phiecl (H2O)) and correspond fairly well with photoluminescence efficiencies. Increased ECL efficiencies (> or = 50-fold) are observed in the presence of the nonionic surfactant Triton X-100.
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Affiliation(s)
- J McCall
- Department of Chemistry, Southwest Missouri State University, Springfield 65804, USA
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Factor B, Muegge B, Workman S, Bolton E, Bos J, Richter MM. Surfactant chain length effects on the light emission of tris(2,2'-bipyridyl)ruthenium(II)/ tripropylamine electrogenerated chemiluminescence. Anal Chem 2001; 73:4621-4. [PMID: 11605839 DOI: 10.1021/ac010698e] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The effects of nonionic surfactant chain length on the properties of tris(2,2'-bipyridyl)ruthenium(II) (Ru(bpy)3(2+) where bpy = 2,2'-bipyridine) electrochemiluminescence (ECL) have been investigated. The electrochemistry, photophysics, and ECL of Ru(bpy)3(2+) in the presence of a series of nonionic surfactants are reported (Triton X-100, 114, 165, 405, 305, and 705-70). These surfactants differ in the number of poly(ethylene oxide) units incorporated into the surfactant molecule. The anodic oxidation of Ru(bpy)3(2+) produces ECL in the presence of tri-n-propylamine (TPrA) in aqueous surfactant solution. Increases in ECL efficiency (> or = 5-fold) and TPrA oxidation current (> or = 2-fold) have been observed in surfactant media. Slight decreases in ECL intensity are observed as the chain length of the nonionic surfactant increases. The data supports adsorption of surfactant on the electrode surface, thus facilitating TPrA and Ru(bpy)3(2+) oxidation and leading to higher ECL efficiencies.
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Affiliation(s)
- B Factor
- Department of Chemistry, Southwest Missouri State University, Springfield 65804, USA
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Workman S. Medical errors and medical culture. Pain relief should have been provided without hesitation. BMJ 2001; 323:570. [PMID: 11573481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Workman S. Physicians, know thy limits. CMAJ 2001; 165:147. [PMID: 11501444 PMCID: PMC81271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
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Workman S. Why are doctors so unhappy? Doctors have conceded their autonomy. BMJ 2001; 322:1365. [PMID: 11409397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
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Singer PA, Barker G, Bowman KW, Harrison C, Kernerman P, Kopelow J, Lazar N, Weijer C, Workman S. Hospital policy on appropriate use of life-sustaining treatment. University of Toronto Joint Centre for Bioethics/Critical Care Medicine Program Task Force. Crit Care Med 2001; 29:187-91. [PMID: 11176183 DOI: 10.1097/00003246-200101000-00037] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the issues faced, and how they were addressed, by the University of Toronto Critical Care Medicine Program/Joint Centre for Bioethics Task Force on Appropriate Use of Life-Sustaining Treatment. The clinical problem addressed by the Task Force was dealing with requests by patients or substitute decision makers for life-sustaining treatment that their healthcare providers believe is inappropriate. DESIGN Case study. SETTING The University of Toronto Joint Centre for Bioethics/Critical Care Medicine Program Task Force on Appropriate Use of Life-Sustaining Treatment. PARTICIPANTS The 24-member Task Force included physician and nursing leaders from five critical care units, bioethicists, a legal scholar, a health administration expert, a social worker, and a hospital public relations professional. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Our specific lessons learned include a) a policy focus on process; b) use of a negotiation and mediation model, rather than a hospital ethics committee model, for this process; and c) the policy development process is itself a negotiation, so we recommend equal involvement of interested groups including patients, families, and the public. CONCLUSIONS This article describes the key issues faced by the Task Force while developing its policy. It will provide a useful starting point for other groups developing policy on appropriate use of life-sustaining treatment.
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Affiliation(s)
- P A Singer
- University of Toronto Joint Centre for Bioethics, Ontario, Canada
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Workman S, Richter MM. The effects of nonionic surfactants on the tris(2,2'-bipyridyl)ruthenium(II)--tripropylamine electrochemiluminescence system. Anal Chem 2000; 72:5556-61. [PMID: 11101231 DOI: 10.1021/ac000800s] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The electrochemistry and electrogenerated chemiluminescence (ECL) of Ru(bpy)3(2+) (bpy = 2,2'-bipyridyl) were studied in the presence of the nonionic surfactants Triton X-100, Thesit, and Nonidet P40. The anodic oxidation of Ru(bpy)3(2+) produces ECL in the presence of tri-n-propylamine in both aqueous and surfactant solutions. Increases in both ECL efficiency (> or =8-fold) and duration of the ECL signal were observed in surfactant media. A shift to lower energies of the Ru(bpy)3(2+) ECL emission by approximately 8 nm was also observed. The one-electron oxidation of Ru(bpy)3(2+) to Ru(bpy)3(3t) occurs at + 1.03 V vs Ag/AgCl in aqueous buffered (0.2 M potassium phosphate) solution as found by square wave voltammetry. This potential did not shift in surfactant systems, indicating that the redshifts in ECL emission are due to stabilization of ligand pi* orbitals in the metal-to-ligand charge-transfer excited state. These results are consistent with hydrophobic interactions between Ru(bpy)3(2+) and the nonionic surfactants.
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Affiliation(s)
- S Workman
- Department of Chemistry, Southwest Missouri State University, Springfield, 65804, USA
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Frieden TR, Ozick L, McCord C, Nainan OV, Workman S, Comer G, Lee TP, Byun KS, Patel D, Henning KJ. Chronic liver disease in central Harlem: the role of alcohol and viral hepatitis. Hepatology 1999; 29:883-8. [PMID: 10051493 DOI: 10.1002/hep.510290308] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
For reasons not yet determined, chronic liver disease (CLD) has been a leading cause of excess morbidity and mortality in central Harlem. We conducted a case series and case-control analysis of demographic, clinical, epidemiological, and alcohol-intake-related information from patients with CLD and age- and sex-matched hospitalized control patients. Patients' sera were tested for markers of viral hepatitis. The presumed etiology of CLD among case-patients was as follows: both alcohol abuse and hepatitis C virus (HCV) infection, 24 persons (46% of case-patients); alcohol abuse alone, 15 (29%); HCV infection alone, 6 (12%); both alcohol abuse and chronic hepatitis B virus (HBV) infection, 3 (6%); and 1 each (2%) from: 1) schistosomiasis, 2) sarcoidosis, 3) unknown causes, and 4) alcohol abuse, chronic HBV, and HCV combined. In the case-control analysis, patients who had both alcoholism and either HBV (odds ratio [OR]: 6.3; 95% CI: 0. 5-334) or HCV (OR: 2.9; 95% CI: 1.3-6.2) were at increased risk for CLD, whereas patients who had only one of these three factors were not at increased risk for CLD. Patients who tested positive for the hepatitis G virus (HGV) did not have a significantly increased risk of CLD, and neither severity of CLD nor mortality was greater among these patients. Most patients in central Harlem who had CLD had liver damage from a combination of alcohol abuse and chronic viral hepatitis. Alcohol and hepatitis viruses appear to be synergistically hepatotoxic; this synergy appears to explain both the high rate of CLD in central Harlem and the recent reductions in this rate. Persons at risk for chronic HBV and HCV infection should be counseled about their increased risk of CLD if they consume excessive alcohol. Morbidity and mortality from liver disease could be decreased further by a reduction in alcohol consumption among persons who have chronic HBV and HCV infection, avoidance of needle sharing, and hepatitis B vaccination.
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Affiliation(s)
- T R Frieden
- New York City Department of Health, New York, USA.
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Workman S. Albumin controversy continues. Lack of efficacy shows that treatments de not work. BMJ 1999; 318:464. [PMID: 10084840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Weijer C, Singer PA, Dickens BM, Workman S. Bioethics for clinicians: 16. Dealing with demands for inappropriate treatment. CMAJ 1998; 159:817-21. [PMID: 9805031 PMCID: PMC1232742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
Demands by Patients or their Families for treatment thought to be inappropriate by health care providers constitute an important set of moral problems in clinical practice. A variety of approaches to such cases have been described in the literature, including medical futility, standard of care and negotiation. Medical futility fails because it confounds morally distinct cases: demand for an ineffective treatment and demand for an effective treatment that supports a controversial end (e.g., permanent unconsciousness). Medical futility is not necessary in the first case and is harmful in the second. Ineffective treatment falls outside the standard of care, and thus health care workers have no obligation to provide it. Demands for treatment that supports controversial ends are difficult cases best addressed through open communication, negotiation and the use of conflict-resolution techniques. Institutions should ensure that fair and unambiguous procedures for dealing with such cases are laid out in policy statements.
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Affiliation(s)
- C Weijer
- Mount Sinai Hospital, Toronto, Ont.
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Workman S. Carcinogen-in-a-can. CMAJ 1998; 159:441. [PMID: 9757160 PMCID: PMC1229630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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Workman S. Thrombolytic therapy for pulmonary embolism. Arch Intern Med 1998; 158:1716. [PMID: 9701107 DOI: 10.1001/archinte.158.15.1716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Workman S. Caring for "difficult" patients. Hastings Cent Rep 1998; 28:4. [PMID: 9762531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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Messeri P, Workman S, Saunders C, Francis C. The application of meta-analysis in assessing racial differences in the effects of antihypertensive medication. J Natl Med Assoc 1997; 89:477-85. [PMID: 9220697 PMCID: PMC2568083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Meta-analysis is an important technique for synthesizing research findings. Although the statistical foundations of meta-analysis continue to be debated, few question its value as a rigorous framework for organizing literature reviews. In recent years, there has been increasing emphasis on the use of meta-analysis not only to summarize the central tendency of findings but also to explain variation between studies. This article reviews the major steps in a meta-analysis with an emphasis on comparative analysis of subgroups of studies. A meta-analysis of the antihypertensive efficacy of calcium channel blockers is used to illustrate how a comparative analysis can be applied to investigate racial variation in the effects of calcium channel blockers. A statistically significant trend is found between the proportion of African-American hypertensive subjects and the mean reduction in blood pressure. Meta-analytic techniques also are applied to explore possible confounders due to differences in research design and patient characteristics.
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Affiliation(s)
- P Messeri
- Urban Health Institute, Harlem Hospital Center, New York, New York, USA
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Workman S. When to scan, when to operate. CMAJ 1997; 157:18, 20. [PMID: 9220937 PMCID: PMC1227657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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35
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Workman S. An impaired judicial system. CMAJ 1997; 156:1698. [PMID: 9220918 PMCID: PMC1227582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Etchells E, Katz MR, Shuchman M, Wong G, Workman S, Choudhry NK, Craven J, Singer PA. Accuracy of clinical impressions and Mini-Mental State Exam scores for assessing capacity to consent to major medical treatment. Comparison with criterion-standard psychiatric assessments. Psychosomatics 1997; 38:239-45. [PMID: 9136252 DOI: 10.1016/s0033-3182(97)71460-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The authors evaluated the accuracy of clinical impressions and Mini-Mental State Exam scores for assessing patient capacity to consent to major medical treatment, relative to expert psychiatric assessment. Consecutive medical inpatients (N = 63) facing a decision about major medical treatment received a clinical impression of capacity from their treating physician and the Standardized Mini-Mental State Exam (SMMSE); 48 received independent psychiatric assessment of capacity. Analyses revealed that both clinical impressions and SMMSE scores were generally inaccurate in determining capacity, although all 23 participants with a clinical impression of "definitely capable" were found capable by the psychiatrist. Given the importance of assessing capacity to consent to major medical treatment, better approaches to the clinical assessment of capacity are required. Several strategies are discussed.
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Affiliation(s)
- E Etchells
- Department of Medicine, Toronto Hospital, Ontario, Canada
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Workman S. Murder-suicide a crisis, not an ethical issue. CMAJ 1995; 153:739. [PMID: 7664220 PMCID: PMC1487274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Leifert C, Li H, Chidburee S, Hampson S, Workman S, Sigee D, Epton HA, Harbour A. Antibiotic production and biocontrol activity by Bacillus subtilis CL27 and Bacillus pumilus CL45. J Appl Bacteriol 1995; 78:97-108. [PMID: 7698955 DOI: 10.1111/j.1365-2672.1995.tb02829.x] [Citation(s) in RCA: 192] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Bacillus subtilis CL27 and B. pumilus CL45 showed similar activity against Botrytis cinerea in in vitro plate assays. In a seedling bioassay, however, B. subtilis CL27 had activity similar to a commercial fungicide while B. pumilus CL45 failed completely to prevent seedling damping-off caused by Bot. cinerea. Antibiotic production by the two Bacillus strains was found to depend on the growth substrate and highest antibiotic production was found on media based on homogenized cabbage tissue. Antibiotic activity was found to depend on the pH and nutrient concentration in the assay medium. Antifungal antibiotics produced by B. subtilis CL27 and B. pumilus CL45 in different fermentation media were separated by thin layer chromatography. As suspected from the activity spectrum, three antibiotics (one with activity against Alternaria brassicicola, one with activity against Botrytis cinerea and one with activity against both fungi) could be detected in the fermentation broth of CL27, but only one in the fermentation broth of CL45. The two antibiotics produced by strain CL27 with activity against A. brassicicola were identified as peptides since their bands on the TLC plates developed a green to blue/green colour after treatment with 4,4'-tetramethyldiamino-diphenylmethane (TDM) reagent. The third antibiotics produced by strain CL27 and antibiotic produced by CL45 had a similar Rf-value and appeared not to be peptides based on the reaction with TDM. However, they showed a slightly different activity spectrum when tested against a range of different fungi. Antibiotic production was clearly indicated as the mode of action of in vivo biocontrol by strain CL27 against damping off caused by Bot. cinerea of Astilbe micro-plants, because a u.v.-induced antibiotic negative mutant strain CL27b showed no activity in seedling bioassays in vivo. Also the mutant strain CL27a which produced the two peptide antibiotics but had lost the ability to produce the non-peptide antibiotic, showed greatly reduced in vivo activity.
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Affiliation(s)
- C Leifert
- Department of Plant and Soil Science, University of Aberdeen, UK
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Abstract
The National Cancer Institute (NCI), in its goal to reduce cancer mortality by 50% by the year 2000, has placed a special emphasis on prevention and early detection, especially in underserved populations. Check-Up On Health is a community based health education program being carried out by Fox Chase Cancer Center in three inner city Philadelphia neighborhoods, to improve the provision of appropriate cancer screening and prevention services to older, blue-collar adults by their primary care physicians. Primary care physicians in the chosen neighborhoods were targeted to receive a brief cancer prevention educational message delivered by project staff and patterned on the model of drug detailing developed by the pharmaceutical industry. This study represents an attempt to evaluate the feasibility and acceptability of such an approach aimed at improving cancer prevention promotion in the health care system. Primary care physicians were identified by community residents who attended one of 67 Check-Up On Health education presentations about cancer prevention at churches, social clubs, and senior-citizen centers within the targeted neighborhoods. An attempt was then made by project staff to visit each identified physician in his/her office or clinic, during office hours, both to conduct a brief survey and to deliver an educational message about either cancer screening guidelines or counseling for smoking cessation. The physicians were also provided with educational materials for themselves as well as their patients. Twelve months after the visit, a follow-up phone call to the physicians assessed the impact of the visit and solicited suggestions for future outreach efforts.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M B Daly
- Division of Population Science, Fox Chase Cancer Center, Philadelphia, PA 19012
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Abstract
Fourteen of 1,500 patients whose serum samples were evaluated by indirect immunofluorescence microscopy had demonstrable titers of anti-intercellular substance (ICS) antibodies in the absence of clinical or histologic evidence of pemphigus. The anti-ICS antibodies were absorbed by A and B blood group antigens in nine of the 14 patients. In five patients, the titers of anti-ICS antibodies were unchanged after absorption with blood group substances. All five of these patients had cicatricial or bullous pemphigoid on clinical, histologic, and immunopathologic examination. Clinical pemphigus did not develop in any of the 14 patients on follow-up examinations conducted for three to 18 months. It seems that anti-ICS antibodies can be produced in several clinical conditions in which there is damage to the epidermis. These anti-ICS antibodies may not have any pathogenetic activity in vivo, at least within the time limits defined by our follow-up examinations.
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