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Stanford GE, Jones M, Charman SC, Bilton D, Usmani OS, Davies JC, Simmonds NJ. Clinimetric analysis of outcome measures for airway clearance in people with cystic fibrosis: a systematic review. Ther Adv Respir Dis 2022; 16:17534666221122572. [PMID: 36066081 PMCID: PMC9459493 DOI: 10.1177/17534666221122572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Airway clearance techniques (ACTs) are integral to cystic fibrosis (CF)
management. However, there is no consensus as to which outcome measures
(OMs) are best for assessing ACT efficacy. Objectives: To summarise OMs that have been assessed for their clinimetric properties
(including validity, feasibility, reliability, and reproducibility) within
the context of ACT research in CF. Design and Methods: A systematic review was conducted according to Preferred Reporting Items for
Systematic Review and Meta-Analysis Protocols (PRISMA) standards. Any
parallel or cross-over randomised controlled trial (RCT) investigating
outcome measures for ACT in the CF population were eligible for inclusion.
The search was performed in five medical databases, clinicaltrials.gov, and
abstracts from international CF conferences. The authors planned to
independently assess study quality and risk of bias using the
COnsensus-based Standards
for the selection of health status Measurement
InstrumeNts (COSMIN) risk
of bias checklist with external validity assessment based upon study details
(participants and study intervention). Two review authors (GS and MJ)
independently screened search results against inclusion criteria, and
further data extraction were planned but not required. Results: No completed RCTs from the 187 studies identified met inclusion criteria for
the primary or post hoc secondary objective. Two ongoing trials were
identified. Discussion and conclusion: This empty systematic review highlights that high-quality RCTs are urgently
needed to investigate and validate the clinimetric properties of OMs used to
assess ACT efficacy. With the changing demographics of CF combined with the
introduction of cystic fibrosis transmembrane conductance regulator (CFTR)
modulator therapies, an accurate assessment of the current benefit of ACT or
the effect of ACT withdrawal is a high priority for clinical practice and
future research; OMs which have been validated for this purpose are
essential. Registration: This systematic review was registered on the PROSPERO database
(CRD42020206033).
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Affiliation(s)
- Gemma E Stanford
- Research Fellow and Highly Specialist Physiotherapist, Department of Adult Cystic Fibrosis, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Mandy Jones
- Department of Health Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK
| | | | - Diana Bilton
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Jane C Davies
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Nicholas J Simmonds
- Department of Adult Cystic Fibrosis, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK.,Omar S. Usmani is now affiliated to Imperial College Respiratory Research Unit, St. Mary's Hospital, London, UK
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Schlüter DK, Ostrenga JS, Carr SB, Fink AK, Faro A, Szczesniak RD, Keogh RH, Charman SC, Marshall BC, Goss CH, Taylor-Robinson D. Lung function in children with cystic fibrosis in the USA and UK: a comparative longitudinal analysis of national registry data. Thorax 2021; 77:136-142. [PMID: 33975926 PMCID: PMC8581063 DOI: 10.1136/thoraxjnl-2021-216849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/30/2021] [Accepted: 04/18/2021] [Indexed: 12/18/2022]
Abstract
Rationale A previous analysis found significantly higher lung function in the US paediatric cystic fibrosis (CF) population compared with the UK with this difference apparently decreasing in adolescence and adulthood. However, the cross-sectional nature of the study makes it hard to interpret these results. Objectives To compare longitudinal trajectories of lung function in children with CF between the USA and UK and to explore reasons for any differences. Methods We used mixed effects regression analysis to model lung function trajectories in the study populations. Using descriptive statistics, we compared early growth and nutrition (height, weight, body mass index), infections (Pseudomonas aeruginosa, Staphylococcus aureus) and treatments (rhDnase, hypertonic saline, inhaled antibiotics). Results We included 9463 children from the USA and 3055 children from the UK with homozygous F508del genotype. Lung function was higher in the USA than in the UK when first measured at age six and remained higher throughout childhood. We did not find important differences in early growth and nutrition, or P.aeruginosa infection. Prescription of rhDNase and hypertonic saline was more common in the USA. Inhaled antibiotics were prescribed at similar levels in both countries, but Tobramycin was prescribed more in the USA and colistin in the UK. S. aureus infection was more common in the USA than the UK. Conclusions Children with CF and homozygous F508del genotype in the USA had better lung function than UK children. These differences do not appear to be explained by early growth or nutrition, but differences in the use of early treatments need further investigation.
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Affiliation(s)
- Daniela K Schlüter
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | | | - Siobhán B Carr
- Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Aliza K Fink
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | - Rhonda D Szczesniak
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ruth H Keogh
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Christopher H Goss
- Departments of Medicine and Pediatrics, University of Washington, Seattle, Washington, USA
| | - David Taylor-Robinson
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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3
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Kaplan S, Lee A, Caine N, Charman SC, Bilton D. Long-term safety study of colistimethate sodium (Colobreathe®): Findings from the UK Cystic Fibrosis Registry. J Cyst Fibros 2020; 20:324-329. [PMID: 32807645 DOI: 10.1016/j.jcf.2020.08.001] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/17/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND As part of the risk management plan in Europe, a long-term observational study was conducted to monitor the safety of colistimethate sodium dry powder for inhalation (CMS-DPI) compared to other inhaled antibiotics. METHODS A cohort of CMS-DPI patients and a matched cohort were identified from the UK Cystic Fibrosis Registry (UKCFR) from 2014-2018. The primary outcome was a composite endpoint, defined as adverse events (AEs) or new cystic fibrosis (CF) complications. Other outcomes included pulmonary exacerbations and treatment discontinuations. RESULTS Of 1466 and 3503 patients in the CMS-DPI and comparator cohorts, respectively, 82.7% and 79.4% had AEs. Among the most common new CF complications were osteopenia, CF-related diabetes, and increased liver enzymes. The adjusted event rate ratio (ERR) for the primary outcome was 1.25 (95% confidence interval [CI]: 1.18-1.33, p<0.001). After excluding new CF complications, there was no difference between cohorts (ERR=1.04, 95% CI: 0.79-1.38, p=0.785). Pulmonary exacerbations were common in CMS-DPI and comparator cohorts (78.0% and 79.9% of patients, respectively), with adjusted ERR of 1.02 (95% CI: 0.95-1.10, p=0.523). Rates of discontinuation were similar in the CMS-DPI and Tobramycin inhalation powder comparator cohorts (37.8% and 39.8% of patients, respectively). CONCLUSIONS There was no difference in the rate of adverse events between CMS-DPI and comparator cohorts. The safety profile of CMS-DPI is similar to those of other inhaled antibiotics, supporting its long-term safety in people with CF. The UKCFR has developed a successful model for partnership with industry to conduct long-term studies aimed at assessing drug safety.
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Affiliation(s)
- Sigal Kaplan
- Teva Pharmaceutical Industries Ltd., Netanya, Israel.
| | - Andrew Lee
- UK Cystic Fibrosis Trust (UKCFT), London, United Kingdom
| | - Noreen Caine
- UK Cystic Fibrosis Trust (UKCFT), London, United Kingdom
| | | | - Diana Bilton
- National Heart and Lung Institute, Imperial College, London & Royal Brompton Hospital, London, United Kingdom
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4
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Eldred-Evans D, Neves JB, Simmons LAM, Kanthabalan A, McCartan N, Shah TT, Arya M, Charman SC, Freeman A, Moore CM, Punwani S, Emberton M, Ahmed HU. Added value of diffusion-weighted images and dynamic contrast enhancement in multiparametric magnetic resonance imaging for the detection of clinically significant prostate cancer in the PICTURE trial. BJU Int 2020; 125:391-398. [PMID: 31733173 DOI: 10.1111/bju.14953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the additional diagnostic value of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced imaging (DCE) in men requiring a repeat biopsy within the PICTURE study. PATIENTS AND METHODS PICTURE was a paired-cohort confirmatory study in which 249 men who required further risk stratification after a previous non-magnetic resonance imaging (MRI)-guided transrectal ultrasonography-guided biopsy underwent a 3-Tesla (3T) multiparametic (mp)MRI consisting of T2-weighted imaging (T2W), DWI and DCE, followed by transperineal template prostate mapping biopsy. Each mpMRI was reported using a LIKERT score in a sequential blinded manner to generate scores for T2W, T2W+DWI and T2W+DWI+DCE. Area under the receiver-operating characteristic curve (AUROC) analysis was performed to compare the diagnostic accuracy of each combination. The threshold for a positive mpMRI was set at a LIKERT score ≥3. Clinically significant prostate cancer was analysed across a range of definitions including UCL/Ahmed definition 1 (primary definition), UCL/Ahmed definition 2, any Gleason ≥3 + 4 and any Gleason ≥4 + 3. RESULTS Of 249 men, sequential MRI reporting was available for 246. There was a higher rate of equivocal lesions (44.6%) using T2W alone compared to the addition of DWI (23.9%) and DCE (19.8%). Using the primary definition of clinically significant disease, there was no significant difference in the overall accuracy between T2W, with an AUROC of 0.74 (95% confidence interval [CI] 0.68-0.80), T2W+DWI at 0.76 (95% CI 0.71-0.82), and T2W+DWI+DCE, with an AUROC of 0.77 (95% CI 0.71-0.82; P = 0.55). The AUROC values remained comparable using other definitions of clinically significant disease including UCL/Ahmed definition 2 (P = 0.79), Gleason ≥3 + 4 (P = 0.53) and Gleason ≥4 + 3 (P = 0.53). CONCLUSIONS Using 3T MRI, a high level of diagnostic accuracy can be achieved using T2W as a single parameter in men with a prior biopsy; however, such a strategy can lead to a higher rate of equivocal lesions.
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Affiliation(s)
- David Eldred-Evans
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Joana B Neves
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, London, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Lucy A M Simmons
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, London, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Abi Kanthabalan
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, London, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Neil McCartan
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, London, UK
| | - Taimur T Shah
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, London, UK
| | - Manit Arya
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, London, UK
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Alex Freeman
- Department of Pathology, UCLH NHS Foundation Trust, London, UK
| | - Caroline M Moore
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, London, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, UCLH NHS Foundation Trust, London, UK
- Centre for Medical Imaging, Division of Medicine, Faculty of Medical Sciences, University College London, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, London, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, London, UK
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5
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Nossiter J, Sujenthiran A, Cowling TE, Parry MG, Charman SC, Cathcart P, Clarke NW, Payne H, van der Meulen J, Aggarwal A. Patient-Reported Functional Outcomes After Hypofractionated or Conventionally Fractionated Radiation for Prostate Cancer: A National Cohort Study in England. J Clin Oncol 2020; 38:744-752. [PMID: 31895608 DOI: 10.1200/jco.19.01538] [Citation(s) in RCA: 13] [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: 02/07/2023] Open
Abstract
PURPOSE The aim of the current study was to determine patient-reported functional outcomes in men with prostate cancer (PCa) undergoing moderately hypofractionated (H-RT) or conventionally fractionated radiation therapy (C-RT) in a national cohort study. PATIENDS AND METHODS All men diagnosed with PCa between April 2014 and September 2016 in the English National Health Service undergoing C-RT or H-RT were identified in the National Prostate Cancer Audit and mailed a questionnaire at least 18 months after diagnosis. We estimated differences in patient-reported urinary, bowel, sexual, and hormonal function-Expanded Prostate Cancer Index Composite short-form 26 domain scores on a 0 to 100 scale-and health-related quality of life-EQ-5D-5L on a 0 to 1 scale-using linear regression with adjustment for patient, tumor, and treatment-related factors in addition to GI and genitourinary baseline function, with higher scores representing better outcomes. RESULTS Of the 17,058 men in the cohort, 77% responded: 8,432 men received C-RT (64.2%) and 4,699 H-RT (35.8%). Men in the H-RT group were older (age ≥ 70 years: 67.5% v 60.9%), fewer men had locally advanced disease (56.5% v 71.3%), were less likely to receive androgen-deprivation therapy (79.5% v 87.8%), and slightly more men had pretreatment genitourinary procedures (24.2% v 21.2%). H-RT was associated with small increases in adjusted mean Expanded Prostate Cancer Index Composite short-form 26 sexual (3.3 points; 95% CI, 2.1 to 4.5; P < .001) and hormonal function scores (3.2 points; 95% CI, 1.8 to 4.6; P < .001). These differences failed to meet established thresholds for a clinically meaningful change. There were no statistically significant differences in urinary or bowel function and quality of life. CONCLUSION This is the first national cohort study comparing functional outcomes after H-RT and C-RT reported by patients. These real-world results further support the use of H-RT as the standard for radiation therapy in men with nonmetastatic PCa.
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Affiliation(s)
- Julie Nossiter
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matthew G Parry
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Noel W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom.,Department of Urology, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, United Kingdom
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ajay Aggarwal
- Department of Cancer Epidemiology, Population, and Global Health, King's College London, London, United Kingdom.,Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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6
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Volkova N, Moy K, Evans J, Campbell D, Tian S, Simard C, Higgins M, Konstan MW, Sawicki GS, Elbert A, Charman SC, Marshall BC, Bilton D. Disease progression in patients with cystic fibrosis treated with ivacaftor: Data from national US and UK registries. J Cyst Fibros 2020; 19:68-79. [DOI: 10.1016/j.jcf.2019.05.015] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/22/2019] [Accepted: 05/20/2019] [Indexed: 11/25/2022]
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Olivier J, Stavrinides V, Kay J, Freeman A, Pye H, Ahmed Z, Carmona Echeverria L, Heavey S, Simmons LAM, Kanthabalan A, Arya M, Briggs T, Barratt D, Charman SC, Gelister J, Hawkes D, Hu Y, Jameson C, McCartan N, Punwani S, van der Muelen J, Moore C, Emberton M, Ahmed HU, Whitaker HC. Immunohistochemical biomarker validation in highly selective needle biopsy microarrays derived from mpMRI-characterized prostates. Prostate 2018; 78:1229-1237. [PMID: 30073682 DOI: 10.1002/pros.23698] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/05/2018] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Diagnosing prostate cancer routinely involves tissue biopsy and increasingly image guided biopsy using multiparametric MRI (mpMRI). Excess tissue after diagnosis can be used for research to improve the diagnostic pathway and the vertical assembly of prostate needle biopsy cores into tissue microarrays (TMAs) allows the parallel immunohistochemical (IHC) validation of cancer biomarkers in routine diagnostic specimens. However, tissue within a biopsy core is often heterogeneous and cancer is not uniformly present, resulting in needle biopsy TMAs that suffer from highly variable cancer detection rates that complicate parallel biomarker validation. MATERIALS AND METHODS The prostate cores with the highest tumor burden (in terms of Gleason score and/or maximum cancer core length) were obtained from 249 patients in the PICTURE trial who underwent transperineal template prostate mapping (TPM) biopsy at 5 mm intervals preceded by mpMRI. From each core, 2 mm segments containing tumor or benign tissue (as assessed on H&E pathology) were selected, excised and embedded vertically into a new TMA block. TMA sections were then IHC-stained for the routinely used prostate cancer biomarkers PSA, PSMA, AMACR, p63, and MSMB and assessed using the h-score method. H-scores in patient matched malignant and benign tissue were correlated with the Gleason grade of the original core and the MRI Likert score for the sampled prostate area. RESULTS A total of 2240 TMA cores were stained and IHC h-scores were assigned to 1790. There was a statistically significant difference in h-scores between patient matched malignant and adjacent benign tissue that is independent of Likert score. There was no association between the h-scores and Gleason grade or Likert score within each of the benign or malignant groups. CONCLUSION The construction of highly selective TMAs from prostate needle biopsy cores is possible. IHC data obtained through this method are highly reliable and can be correlated with imaging. IHC expression patterns for PSA, PSMA, AMACR, p63, and MSMB are distinct in malignant and adjacent benign tissue but did not correlate with mpMRI Likert score.
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Affiliation(s)
- Jonathan Olivier
- Molecular Diagnostics and Therapeutics Group, Charles Bell House, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Urology, Hospital Huriez, University Lille Nord de France, Lille, France
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Vasilis Stavrinides
- Molecular Diagnostics and Therapeutics Group, Charles Bell House, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Jonathan Kay
- Molecular Diagnostics and Therapeutics Group, Charles Bell House, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Alex Freeman
- Department of Pathology, UCLH NHS Foundation Trust, London, United Kingdom
| | - Hayley Pye
- Molecular Diagnostics and Therapeutics Group, Charles Bell House, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Zeba Ahmed
- Molecular Diagnostics and Therapeutics Group, Charles Bell House, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Lina Carmona Echeverria
- Molecular Diagnostics and Therapeutics Group, Charles Bell House, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Susan Heavey
- Molecular Diagnostics and Therapeutics Group, Charles Bell House, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Lucy A M Simmons
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Urology, UCLH NHS Foundation Trust, London, United Kingdom
| | - Abi Kanthabalan
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Urology, UCLH NHS Foundation Trust, London, United Kingdom
| | - Manit Arya
- Department of Urology, UCLH NHS Foundation Trust, London, United Kingdom
| | - Tim Briggs
- Department of Urology, UCLH NHS Foundation Trust, London, United Kingdom
- Department of Urology, The Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Dean Barratt
- Department of Computer Science, Centre for Medical Imaging and Computing, University College London, London, United Kingdom
| | - Susan C Charman
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - James Gelister
- Department of Urology, The Royal Free London NHS Foundation Trust, London, United Kingdom
| | - David Hawkes
- Department of Computer Science, Centre for Medical Imaging and Computing, University College London, London, United Kingdom
| | - Yipeng Hu
- Department of Computer Science, Centre for Medical Imaging and Computing, University College London, London, United Kingdom
| | - Charles Jameson
- Department of Pathology, UCLH NHS Foundation Trust, London, United Kingdom
| | - Neil McCartan
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Urology, UCLH NHS Foundation Trust, London, United Kingdom
| | - Shonit Punwani
- Faculty of Medicine, Department of Radiology, UCLH NHS Foundation Trust, London, United Kingdom
| | - Jan van der Muelen
- Department of Pathology, UCLH NHS Foundation Trust, London, United Kingdom
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Caroline Moore
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Urology, UCLH NHS Foundation Trust, London, United Kingdom
| | - Mark Emberton
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Urology, UCLH NHS Foundation Trust, London, United Kingdom
| | - Hashim U Ahmed
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Hayley C Whitaker
- Molecular Diagnostics and Therapeutics Group, Charles Bell House, Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, United Kingdom
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8
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Simmons LAM, Kanthabalan A, Arya M, Briggs T, Barratt D, Charman SC, Freeman A, Hawkes D, Hu Y, Jameson C, McCartan N, Moore CM, Punwani S, van der Muelen J, Emberton M, Ahmed HU. Accuracy of Transperineal Targeted Prostate Biopsies, Visual Estimation and Image Fusion in Men Needing Repeat Biopsy in the PICTURE Trial. J Urol 2018; 200:1227-1234. [PMID: 30017964 DOI: 10.1016/j.juro.2018.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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] [Accepted: 07/03/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE We evaluated the detection of clinically significant prostate cancer using magnetic resonance imaging targeted biopsies and compared visual estimation to image fusion targeting in patients requiring repeat prostate biopsies. MATERIALS AND METHODS The prospective, ethics committee approved PICTURE trial (ClinicalTrials.gov NCT01492270) enrolled 249 consecutive patients from January 11, 2012 to January 29, 2014. Men underwent multiparametric magnetic resonance imaging and were blinded to the results. All underwent transperineal template prostate mapping biopsies. In 200 men with a lesion this was preceded by visual estimation and image fusion targeted biopsies. As the primary study end point clinically significant prostate cancer was defined as Gleason 4 + 3 or greater and/or any grade of cancer with a length of 6 mm or greater. Other definitions of clinically significant prostate cancer were also evaluated. RESULTS Mean ± SD patient age was 62.6 ± 7 years, median prostate specific antigen was 7.17 ng/ml (IQR 5.25-10.09), mean primary lesion size was 0.37 ± 1.52 cc with a mean of 4.3 ± 2.3 targeted cores per lesion on visual estimation and image fusion combined, and a mean of 48.7 ± 12.3 transperineal template prostate mapping biopsy cores. Transperineal template prostate mapping biopsies detected 97 clinically significant prostate cancers (48.5%) and 85 insignificant cancers (42.5%). Overall multiparametric magnetic resonance imaging targeted biopsies detected 81 clinically significant prostate cancers (40.5%) and 63 insignificant cancers (31.5%). In the 18 cases (9%) of clinically significant prostate cancer on magnetic resonance imaging targeted biopsies were benign or clinically insignificant on transperineal template prostate mapping biopsy. Clinically significant prostate cancer was detected in 34 cases (17%) on transperineal template prostate mapping biopsy but not on magnetic resonance imaging targeted biopsies and approximately half was present in nontargeted areas. Clinically significant prostate cancer was found on visual estimation and image fusion in 53 (31.3%) and 48 (28.4%) of the 169 patients (McNemar test p = 0.5322). Visual estimation missed 23 clinically significant prostate cancers (13.6%) detected by image fusion. Image fusion missed 18 clinically significant prostate cancers (10.8%) detected by visual estimation. CONCLUSIONS Magnetic resonance imaging targeted biopsies are accurate for detecting clinically significant prostate cancer and reducing the over diagnosis of insignificant cancers. To maximize detection visual estimation as well as image fusion targeted biopsies are required.
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Affiliation(s)
- Lucy A M Simmons
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, United Kingdom; Department of Urology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Abi Kanthabalan
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, United Kingdom; Department of Urology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Manit Arya
- Department of Urology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Tim Briggs
- Department of Urology, University College London Hospital NHS Foundation Trust, London, United Kingdom; Department of Urology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Dean Barratt
- Centre for Medical Imaging and Computing, Department of Computer Science, University College London, London, United Kingdom
| | - Susan C Charman
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alex Freeman
- Department of Pathology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - David Hawkes
- Centre for Medical Imaging and Computing, Department of Computer Science, University College London, London, United Kingdom
| | - Yipeng Hu
- Centre for Medical Imaging and Computing, Department of Computer Science, University College London, London, United Kingdom
| | - Charles Jameson
- Department of Pathology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Neil McCartan
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, United Kingdom; Department of Urology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Caroline M Moore
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, United Kingdom; Department of Urology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Shonit Punwani
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Jan van der Muelen
- Department of Pathology, University College London Hospital NHS Foundation Trust, London, United Kingdom; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
| | - Mark Emberton
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, United Kingdom; Department of Urology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Hashim U Ahmed
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, United Kingdom; Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.
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9
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Yue D, Cooper LRL, Kerstein R, Charman SC, Kang NV. Defining Normal Parameters for the Male Nipple-Areola Complex: A Prospective Observational Study and Recommendations for Placement on the Chest Wall. Aesthet Surg J 2018; 38:742-748. [PMID: 29329370 DOI: 10.1093/asj/sjx245] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The nipple-areola complex (NAC) is important aesthetically and functionally for both sexes. Methods for positioning the NAC in males are less well established in the literature compared to females but are just as important. OBJECTIVES This study aims to determine the normal parameters for the male NAC, to review literature, and to present a reliable method for preoperative placement. METHODS Normal male patients, with no prior chest wall conditions, were prospectively recruited to participate. General demographics and chest wall dimensions were recorded-sternal notch to nipple (SNND), internipple (IND), anterior axillary folds distances (AFD), NAC, and chest circumference were measured. Comparisons were made using t test and ANOVA. RESULTS One hundred and fifty-eight patients were recruited (age range, 18-90 years); mostly (86.7%) with normal or overweight BMI. The IND averaged 249.4 mm, the SNND averaged 204.2 mm, and the AFD averaged 383.8 mm. Areola diameter averaged 26.6 mm and for the nipple, 6.9 mm. The IND:AFD ratio was 0.65. There was no statistical difference in the IND:AFD ratio, SNND, or NAC parameters comparing different ethnic groups. The SNND increased with greater BMI (P ≤ 0.001). Using these data, we suggest ideal NAC dimensions and devised a simple method for positioning of the NAC on the male chest wall. CONCLUSIONS This is the largest study, with the widest range in age and BMI, to date on this topic. Although fewer men than women undergo surgery to the breast, there is a growing awareness for enhancing the appearance of the male chest wall. LEVEL OF EVIDENCE 4
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Affiliation(s)
- Dominic Yue
- Plastic Surgery Department, Royal Free Hospital, Pond Street, London, England
| | - Lilli R L Cooper
- Plastic Surgery Department, Royal Free Hospital, Pond Street, London, England
| | - Ryan Kerstein
- Plastic Surgery Department, Royal Free Hospital, Pond Street, London, England
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | - Norbert V Kang
- Plastic Surgery Department, Royal Free Hospital, Pond Street, London, England
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10
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Vallance AE, van der Meulen J, Kuryba A, Charman SC, Botterill ID, Prasad KR, Hill J, Jayne DG, Walker K. The timing of liver resection in patients with colorectal cancer and synchronous liver metastases: a population-based study of current practice and survival. Colorectal Dis 2018; 20:486-495. [PMID: 29338108 DOI: 10.1111/codi.14019] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/12/2017] [Indexed: 12/13/2022]
Abstract
AIM There is uncertainty regarding the optimal sequence of surgery for patients with colorectal cancer (CRC) and synchronous liver metastases. This study was designed to describe temporal trends and inter-hospital variation in surgical strategy, and to compare long-term survival in a propensity score-matched analysis. METHOD The National Bowel Cancer Audit dataset was used to identify patients diagnosed with primary CRC between 1 January 2010 and 31 December 2015 who underwent CRC resection in the English National Health Service. Hospital Episode Statistics data were used to identify those with synchronous liver-limited metastases who underwent liver resection. Survival outcomes of propensity score-matched groups were compared. RESULTS Of 1830 patients, 270 (14.8%) underwent a liver-first approach, 259 (14.2%) a simultaneous approach and 1301 (71.1%) a bowel-first approach. The proportion of patients undergoing either a liver-first or simultaneous approach increased over the study period from 26.8% in 2010 to 35.6% in 2015 (P < 0.001). There was wide variation in surgical approach according to hospital trust of diagnosis. There was no evidence of a difference in 4-year survival between the propensity score-matched cohorts according to surgical strategy: bowel first vs simultaneous [hazard ratio (HR) 0.92 (95% CI: 0.80-1.06)] or bowel first vs liver first [HR 0.99 (95% CI: 0.82-1.19)]. CONCLUSION There is evidence of wide variation in surgical strategy in dealing with CRC and synchronous liver metastases. In selected patients, the simultaneous and liver-first strategies have comparable long-term survival to the bowel-first approach.
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Affiliation(s)
- A E Vallance
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - J van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - A Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - S C Charman
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - K R Prasad
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - J Hill
- Department of General Surgery, Manchester Royal Infirmary, Manchester, UK
| | - D G Jayne
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - K Walker
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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11
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Sujenthiran A, Nossiter J, Parry M, Charman SC, Cathcart PJ, van der Meulen J, Clarke NW, Payne H, Aggarwal A. Treatment-related toxicity in men who received Intensity-modulated versus 3D-conformal radiotherapy after radical prostatectomy: A national population-based study. Radiother Oncol 2018; 128:357-363. [PMID: 29773442 DOI: 10.1016/j.radonc.2018.04.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/25/2018] [Accepted: 04/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE In the post-prostatectomy setting the value of Intensity-modulated (IMRT) relative to 3D-conformal radiotherapy (3D-CRT) in reducing toxicity remains unclear. We compared genitourinary (GU) and gastrointestinal (GI) toxicity after post-prostatectomy IMRT or 3D-CRT. MATERIALS AND METHODS A population-based study of all patients treated with post-prostatectomy 3D-CRT (n = 2422) and IMRT (n = 603) was conducted between January 1 2010 and December 31 2013 in the English National Health Service. We identified severe GI and GU toxicity using a validated coding-framework and compared IMRT and 3D-CRT using a competing-risks proportional hazards regression analysis. RESULTS There was no difference in GI toxicity between patients who received IMRT and 3D-CRT (3D-CRT: 5.8 events/100 person-years; IMRT: 5.5 events/100 person-years; adjusted HR: 0.85, 95%CI: 0.63-1.13; p = 0.26). The GU toxicity rate was lower with IMRT but this effect was not statistically significant (3D-CRT: 5.4 events/100 person-years; IMRT: 3.8 events/100 person-years; adjusted HR: 0.76, 95%CI: 0.55-1.03; p = 0.08). CONCLUSIONS The use of post-prostatectomy IMRT compared to 3D-CRT is not associated with a statistically significant reduction in rates of severe GU and GI toxicity, although there is some evidence that GU toxicity is lower with IMRT. We would caution against rapid transition to post-prostatectomy IMRT until further evidence is available supporting its superiority.
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Affiliation(s)
- Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeon of England, London, United Kingdom.
| | - Julie Nossiter
- Clinical Effectiveness Unit, Royal College of Surgeon of England, London, United Kingdom
| | - Matthew Parry
- Clinical Effectiveness Unit, Royal College of Surgeon of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Susan C Charman
- Clinical Effectiveness Unit, Royal College of Surgeon of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Paul J Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, United Kingdom
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, United Kingdom
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom; Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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12
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Fitzsimons KJ, Copley LP, Setakis E, Charman SC, Deacon SA, Dearden L, van der Meulen JH. Early academic achievement in children with isolated clefts: a population-based study in England. Arch Dis Child 2018; 103:356-362. [PMID: 29097368 PMCID: PMC5890634 DOI: 10.1136/archdischild-2017-313777] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/28/2017] [Accepted: 09/13/2017] [Indexed: 12/04/2022]
Abstract
OBJECTIVES We used national data to study differences in academic achievement between 5-year-old children with an isolated oral cleft and the general population. We also assessed differences by cleft type. METHODS Children born in England with an oral cleft were identified in a national cleft registry. Their records were linked to databases of hospital admissions (to identify additional anomalies) and educational outcomes. Z-scores (signed number of SD actual score is above national average) were calculated to make outcome scores comparable across school years and across six assessed areas (personal development, communication and language, maths, knowledge of world, physical development andcreative development). RESULTS 2802 children without additional anomalies, 5 years old between 2006 and 2012, were included. Academic achievement was significantly below national average for all six assessed areas with z-scores ranging from -0.24 (95% CI -0.32 to -0.16) for knowledge of world to -0.31 (-0.38 to -0.23) for personal development. Differences were small with only a cleft lip but considerably larger with clefts involving the palate. 29.4% of children were documented as having special education needs (national rate 9.7%), which varied according to cleft type from 13.2% with cleft lip to 47.6% with bilateral cleft lip and palate. CONCLUSIONS Compared with national average, 5-year-old children with an isolated oral cleft, especially those involving the palate, have significantly poorer academic achievement across all areas of learning. These outcomes reflect results of modern surgical techniques and multidisciplinary approach. Children with a cleft may benefit from extra academic support when starting school.
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Affiliation(s)
| | - Lynn P Copley
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Efrosini Setakis
- UCL Institute of Education, University College London, London, UK
| | - Susan C Charman
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Scott A Deacon
- University Hospitals Bristol NHS Foundation Trust, London, UK
| | - Lorraine Dearden
- UCL Institute of Education, University College London, London, UK
| | - Jan H van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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13
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Sujenthiran A, Nossiter J, Parry M, Charman SC, Aggarwal A, Payne H, Dasgupta P, Clarke NW, van der Meulen J, Cathcart P. National cohort study comparing severe medium-term urinary complications after robot-assisted vs laparoscopic vs retropubic open radical prostatectomy. BJU Int 2018; 121:445-452. [PMID: 29032582 PMCID: PMC5873443 DOI: 10.1111/bju.14054] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the occurrence of severe urinary complications within 2 years of surgery in men undergoing either robot-assisted radical prostatectomy (RARP), laparoscopic radical prostatectomy (LRP) or retropubic open radical prostatectomy (ORP). PATIENTS AND METHODS We conducted a population-based cohort study in men who underwent RARP (n = 4 947), LRP (n = 5 479) or ORP (n = 6 873) between 2008 and 2012 in the English National Health Service (NHS) using national cancer registry records linked to Hospital Episodes Statistics, an administrative database of admissions to NHS hospitals. We identified the occurrence of any severe urinary or severe stricture-related complication within 2 years of surgery using a validated tool. Multi-level regression modelling was used to determine the association between the type of surgery and occurrence of complications, with adjustment for patient and surgical factors. RESULTS Men undergoing RARP were least likely to experience any urinary complication (10.5%) or a stricture-related complication (3.3%) compared with those who had LRP (15.8% any or 5.7% stricture-related) or ORP (19.1% any or 6.9% stricture-related). The impact of the type of surgery on the occurrence of any urinary or stricture-related complications remained statistically significant after adjustment for patient and surgical factors (P < 0.01). CONCLUSION Men who underwent RARP had the lowest risk of developing severe urinary complications within 2 years of surgery.
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Affiliation(s)
| | - Julie Nossiter
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Matthew Parry
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Susan C. Charman
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Ajay Aggarwal
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Heather Payne
- Department of OncologyUniversity College London HospitalsLondonUK
| | | | - Noel W. Clarke
- Department of UrologyChristie and Salford Royal NHS Foundation TrustsManchesterUK
| | - Jan van der Meulen
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Paul Cathcart
- Department of UrologyGuy's and St Thomas' NHS Foundation TrustLondonUK
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14
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Nossiter J, Sujenthiran A, Charman SC, Cathcart PJ, Aggarwal A, Payne H, Clarke NW, van der Meulen J. Robot-assisted radical prostatectomy vs laparoscopic and open retropubic radical prostatectomy: functional outcomes 18 months after diagnosis from a national cohort study in England. Br J Cancer 2018; 118:489-494. [PMID: 29348490 PMCID: PMC5830598 DOI: 10.1038/bjc.2017.454] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 11/16/2017] [Accepted: 11/21/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Robot-assisted radical prostatectomy (RARP) has been rapidly adopted without robust evidence comparing its functional outcomes against laparoscopic radical prostatectomy (LRP) or open retropubic radical prostatectomy (ORP) approaches. This study compared patient-reported functional outcomes following RARP, LRP or ORP. METHODS All men diagnosed with prostate cancer in England during April - October 2014 who underwent radical prostatectomy were identified from the National Prostate Cancer Audit and mailed a questionnaire 18 months after diagnosis. Group differences in patient-reported sexual, urinary, bowel and hormonal function (EPIC-26 domain scores) and generic health-related quality of life (HRQoL; EQ-5D-5L scores), with adjustment for patient and tumour characteristics, were estimated using linear regression. RESULTS In all, 2219 men (77.0%) responded; 1310 (59.0%) had RARP, 487 (21.9%) LRP and 422 (19.0%) ORP. RARP was associated with slightly higher adjusted mean EPIC-26 sexual function scores compared with LRP (3·5 point difference; 95% CI: 1.1-5.9, P=0.004) or ORP (4.0 point difference; 95% CI: 1.5-6.5, P=0.002), which did not meet the threshold for a minimal clinically important difference (10-12 points). There were no significant differences in other EPIC-26 domain scores or HRQoL. CONCLUSIONS It is unlikely that the rapid adoption of RARP in the English NHS has produced substantial improvements in functional outcomes for patients.
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Affiliation(s)
- Julie Nossiter
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
| | - Susan C Charman
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
| | - Paul J Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
| | - Ajay Aggarwal
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
| | - Noel W Clarke
- Department of Urology, The Christie, Manchester M20 4BX, UK
- Department of Urology, Salford Royal NHS Foundation Trusts, Manchester M6 8HD, UK
| | - Jan van der Meulen
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
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15
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Luckraz H, Manga N, Senanayake EL, Abdelaziz M, Gopal S, Charman SC, Giri R, Oppong R, Andronis L. Cost of treating ventilator-associated pneumonia post cardiac surgery in the National Health Service: Results from a propensity-matched cohort study. J Intensive Care Soc 2017; 19:94-100. [PMID: 29796064 DOI: 10.1177/1751143717740804] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Ventilator-associated pneumonia is associated with significant morbidity, mortality and healthcare costs. Most of the cost data that are available relate to general intensive care patients in privately remunerated institutions. This study assessed the cost of managing ventilator-associated pneumonia in a cardiac intensive care unit in the National Health Service in the United Kingdom. Methods Propensity-matched study of prospectively collected data from the cardiac surgical database between April 2011 and December 2014 in all patients undergoing cardiac surgery (n = 3416). Patients who were diagnosed as developing ventilator-associated pneumonia, as per the surveillance definition for ventilator-associated pneumonia (n = 338), were propensity score matched with those who did not (n = 338). Costs of treating post-op cardiac surgery patients in intensive care and cost difference if ventilator-associated pneumonia occurred based on Healthcare Resource Group categories were assessed. Secondary outcomes included differences in morbidity, mortality and cardiac intensive care unit and in-hospital length of stay. Results There were no significant differences in the pre-operative characteristics or procedures between the groups. Ventilator-associated pneumonia developed in 10% of post-cardiac surgery patients. Post-operatively, the ventilator-associated pneumonia group required longer ventilation (p < 0.01), more respiratory support, longer cardiac intensive care unit (8 vs 3, p < 0.001) and in-hospital stay (16 vs 9) days. The overall cost for post-operative recovery after cardiac surgery for ventilator-associated pneumonia patients was £15,124 compared to £6295 for non-ventilator-associated pneumonia (p < 0.01). The additional cost of treating patients with ventilator-associated pneumonia was £8829. Conclusion Ventilator-associated pneumonia was associated with significant morbidity to the patients, generating significant costs. This cost was nearer to the lower end for the cost for general intensive care unit patients in privately reimbursed systems.
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Affiliation(s)
- Heyman Luckraz
- 1Cardiothoracic Surgery Department, New Cross Hospital, Royal Wolverhampton NHS Trust, UK
| | | | - Eshan L Senanayake
- 1Cardiothoracic Surgery Department, New Cross Hospital, Royal Wolverhampton NHS Trust, UK
| | - Mahmoud Abdelaziz
- 1Cardiothoracic Surgery Department, New Cross Hospital, Royal Wolverhampton NHS Trust, UK
| | - Shameer Gopal
- 3Intensive Care Department, New Cross Hospital, Royal Wolverhampton NHS Trust, UK
| | - Susan C Charman
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, UK
| | - Ramesh Giri
- 5Cardiothoracic Anaesthesiology Department, New Cross Hospital, Royal Wolverhampton NHS Trust, UK
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16
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Green R, Charman SC, Palser T. Early definitive treatment rate as a quality indicator of care in acute gallstone pancreatitis. Br J Surg 2017; 104:1686-1694. [PMID: 28792589 DOI: 10.1002/bjs.10578] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 11/26/2016] [Accepted: 04/04/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Early definitive treatment (cholecystectomy or endoscopic sphincterotomy in the same admission or within 2 weeks after discharge) of gallstone disease after a biliary attack of acute pancreatitis is standard of care. This study investigated whether compliance with early definitive treatment for acute gallstone pancreatitis can be used as a care quality indicator for the condition. METHODS A retrospective cohort study was conducted using the Hospital Episode Statistics database. All emergency admissions to National Health Service hospitals in England with a first time diagnosis of acute gallstone pancreatitis in the financial years 2008, 2009 and 2010 were examined. Trends in early definitive treatment between hospital trusts were examined and patient morbidity outcomes were determined. RESULTS During the study interval there were 19 510 patients with an overall rate of early definitive treatment at 34·7 (range 9·4-84·7) per cent. In the 1-year follow-up period, 4661 patients (23·9 per cent) had one or more emergency readmissions for complications related to gallstone pancreatitis. Of these, 2692 (57·8 per cent) were readmissions for acute pancreatitis; 911 (33·8 per cent) were within the first 2 weeks of discharge, with the remaining 1781 (66·2 per cent) occurring after the point at which definitive treatment should have been received. Early definitive treatment resulted in a 39 per cent reduction in readmission risk (adjusted risk ratio (RR) 0·61, 95 per cent c.i. 0·58 to 0·65). The risk was further reduced for acute pancreatitis readmissions to 54 per cent in the early definitive treatment group (adjusted RR 0·46, 0·42 to 0·51). CONCLUSION In acute gallstone pancreatitis, compliance with recommended early definitive treatment varied considerably, with associated variation in outcomes. Compliance should be used as a quality indicator to improve care.
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Affiliation(s)
- R Green
- Anaesthetics Department, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - S C Charman
- Clinical Effectiveness Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - T Palser
- Department of Upper Gastrointestinal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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17
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Simmons LAM, Kanthabalan A, Arya M, Briggs T, Barratt D, Charman SC, Freeman A, Gelister J, Hawkes D, Hu Y, Jameson C, McCartan N, Moore CM, Punwani S, Ramachandran N, van der Meulen J, Emberton M, Ahmed HU. The PICTURE study: diagnostic accuracy of multiparametric MRI in men requiring a repeat prostate biopsy. Br J Cancer 2017; 116:1159-1165. [PMID: 28350785 PMCID: PMC5418442 DOI: 10.1038/bjc.2017.57] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 01/22/2017] [Accepted: 02/06/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Transrectal prostate biopsy has limited diagnostic accuracy. Prostate Imaging Compared to Transperineal Ultrasound-guided biopsy for significant prostate cancer Risk Evaluation (PICTURE) was a paired-cohort confirmatory study designed to assess diagnostic accuracy of multiparametric magnetic resonance imaging (mpMRI) in men requiring a repeat biopsy. METHODS All underwent 3 T mpMRI and transperineal template prostate mapping biopsies (TTPM biopsies). Multiparametric MRI was reported using Likert scores and radiologists were blinded to initial biopsies. Men were blinded to mpMRI results. Clinically significant prostate cancer was defined as Gleason ⩾4+3 and/or cancer core length ⩾6 mm. RESULTS Two hundred and forty-nine had both tests with mean (s.d.) age was 62 (7) years, median (IQR) PSA 6.8 ng ml (4.98-9.50), median (IQR) number of previous biopsies 1 (1-2) and mean (s.d.) gland size 37 ml (15.5). On TTPM biopsies, 103 (41%) had clinically significant prostate cancer. Two hundred and fourteen (86%) had a positive prostate mpMRI using Likert score ⩾3; sensitivity was 97.1% (95% confidence interval (CI): 92-99), specificity 21.9% (15.5-29.5), negative predictive value (NPV) 91.4% (76.9-98.1) and positive predictive value (PPV) 46.7% (35.2-47.8). One hundred and twenty-nine (51.8%) had a positive mpMRI using Likert score ⩾4; sensitivity was 80.6% (71.6-87.7), specificity 68.5% (60.3-75.9), NPV 83.3% (75.4-89.5) and PPV 64.3% (55.4-72.6). CONCLUSIONS In men advised to have a repeat prostate biopsy, prostate mpMRI could be used to safely avoid a repeat biopsy with high sensitivity for clinically significant cancers. However, such a strategy can miss some significant cancers and overdiagnose insignificant cancers depending on the mpMRI score threshold used to define which men should be biopsied.
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Affiliation(s)
- Lucy A M Simmons
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, 21 University Street, London WC1E 7PN, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Abi Kanthabalan
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, 21 University Street, London WC1E 7PN, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Manit Arya
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Tim Briggs
- Department of Urology, UCLH NHS Foundation Trust, London, UK
- Department of Urology, The Royal Free London NHS Foundation Trust, London, UK
| | - Dean Barratt
- Centre for Medical Imaging and Computing, Department of Computer Science, University College London, London, UK
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Alex Freeman
- Department of Pathology, UCLH NHS Foundation Trust London, UK
| | - James Gelister
- Department of Urology, The Royal Free London NHS Foundation Trust, London, UK
| | - David Hawkes
- Centre for Medical Imaging and Computing, Department of Computer Science, University College London, London, UK
| | - Yipeng Hu
- Centre for Medical Imaging and Computing, Department of Computer Science, University College London, London, UK
| | - Charles Jameson
- Department of Pathology, UCLH NHS Foundation Trust London, UK
| | - Neil McCartan
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, 21 University Street, London WC1E 7PN, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Caroline M Moore
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, 21 University Street, London WC1E 7PN, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, UCLH NHS Foundation Trust, London, UK
- Centre for Medical Imaging, Division of Medicine, Faculty of Medical Sciences, University College London, London, UK
| | | | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, 21 University Street, London WC1E 7PN, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Hashim U Ahmed
- Division of Surgery and Interventional Science, University College London, Faculty of Medical Sciences, 21 University Street, London WC1E 7PN, UK
- Department of Urology, UCLH NHS Foundation Trust, London, UK
- Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
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18
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Sujenthiran A, Charman SC, Parry M, Nossiter J, Aggarwal A, Dasgupta P, Payne H, Clarke NW, Cathcart P, van der Meulen J. Quantifying severe urinary complications after radical prostatectomy: the development and validation of a surgical performance indicator using hospital administrative data. BJU Int 2017; 120:219-225. [PMID: 28075516 DOI: 10.1111/bju.13770] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To develop and validate a surgical performance indicator based on severe urinary complications that require an intervention within 2 years of radical prostatectomy (RP), identified in hospital administrative data. PATIENTS AND METHODS Men who underwent RP between 2008 and 2012 in England were identified using hospital administrative data. A transparent coding framework based on procedure codes was developed to identify severe urinary complications which were grouped into 'stricture', 'incontinence' and 'other'. Their validity as a performance indicator was assessed by evaluating the consistency with diagnosis codes and association with patient and surgical characteristics. Kaplan-Meier methods were used to assess time to first occurrence and multivariable logistic regression was used to estimate adjusted odds ratios (ORs) for patient and surgical characteristics. RESULTS A total of 17 299 men were included, of whom 2695 (15.6%) experienced at least one severe urinary complication within 2 years. High proportions of men with a complication had relevant diagnosis codes: 86% for strictures and 93% for incontinence. Urinary complications were more common in men from poorer socio-economic backgrounds (OR comparing lowest with highest quintile: 1.45; 95% confidence interval [CI] 1.26-1.67) and in those with prolonged length of hospital stay (OR 1.54, 95% CI 1.40-1.69), and were less common in men who underwent robot-assisted surgery (OR 0.65, 95% CI 0.58-0.74). CONCLUSION These results show that severe urinary complications identified in administrative data provide a medium-term performance indicator after RP. They can be used for research assessing outcomes of treatment methods and for service evaluation comparing performance of prostate cancer surgery providers.
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Affiliation(s)
- Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Susan C Charman
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Parry
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Julie Nossiter
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Ajay Aggarwal
- London School of Hygiene and Tropical Medicine, London, UK
| | - Prokar Dasgupta
- MRC Centre for Transplantation, King's College London, London, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Noel W Clarke
- Department of Urology, Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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19
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Tovikkai C, Charman SC, Praseedom RK, Gimson AE, van der Meulen J. Time spent in hospital after liver transplantation: Effects of primary liver disease and comorbidity. World J Transplant 2016; 6:743-750. [PMID: 28058226 PMCID: PMC5175234 DOI: 10.5500/wjt.v6.i4.743] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/28/2016] [Accepted: 11/02/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To explore the effect of primary liver disease and comorbidities on transplant length of stay (TLOS) and LOS in later admissions in the first two years after liver transplantation (LLOS).
METHODS A linked United Kingdom Liver Transplant Audit - Hospital Episode Statistics database of patients who received a first adult liver transplant between 1997 and 2010 in England was analysed. Patients who died within the first two years were excluded from the primary analysis, but a sensitivity analysis was also performed including all patients. Multivariable linear regression was used to evaluate the impact of primary liver disease and comorbidities on TLOS and LLOS.
RESULTS In 3772 patients, the mean (95%CI) TLOS was 24.8 (24.2 to 25.5) d, and the mean LLOS was 24.2 (22.9 to 25.5) d. Compared to patients with cancer, we found that the largest difference in TLOS was seen for acute hepatic failure group (6.1 d; 2.8 to 9.4) and the largest increase in LLOS was seen for other liver disease group (14.8 d; 8.1 to 21.5). Patients with cardiovascular disease had 8.5 d (5.7 to 11.3) longer TLOS and 6.0 d (0.2 to 11.9) longer LLOS, compare to those without. Patients with congestive cardiac failure had 7.6 d longer TLOS than those without. Other comorbidities did not significantly increase TLOS nor LLOS.
CONCLUSION The time patients spent in hospital varied according to their primary liver disease and some comorbidities. Time spent in hospital of patients with cancer was relatively short compared to most other indications. Cardiovascular disease and congestive cardiac failure were the comorbidities with a strong impact on increased LOS.
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20
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Dickinson L, Arya M, Afzal N, Cathcart P, Charman SC, Cornaby A, Hindley RG, Lewi H, McCartan N, Moore CM, Nathan S, Ogden C, Persad R, van der Meulen J, Weir S, Emberton M, Ahmed HU. Medium-term Outcomes after Whole-gland High-intensity Focused Ultrasound for the Treatment of Nonmetastatic Prostate Cancer from a Multicentre Registry Cohort. Eur Urol 2016; 70:668-674. [PMID: 26951947 DOI: 10.1016/j.eururo.2016.02.054] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 02/18/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND High-intensity focused ultrasound (HIFU) is a minimally-invasive treatment for nonmetastatic prostate cancer. OBJECTIVE To report medium-term outcomes in men receiving primary whole-gland HIFU from a national multi-centre registry cohort. DESIGN, SETTING, AND PARTICIPANTS Five-hundred and sixty-nine patients at eight hospitals were entered into an academic registry. INTERVENTION Whole-gland HIFU (Sonablate 500) for primary nonmetastatic prostate cancer. Redo-HIFU was permitted as part of the intervention. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Our primary failure-free survival outcome incorporated no transition to any of the following: (1) local salvage therapy (surgery or radiotherapy), (2) systemic therapy, (3) metastases, or (4) prostate cancer-specific mortality. Secondary outcomes included adverse events and genitourinary function. RESULTS AND LIMITATIONS Mean age was 65 yr (47-87 yr). Median prostate-specific antigen was 7.0 ng/ml (interquartile range 4.4-10.2). National Comprehensive Cancer Network low-, intermediate-, and high-risk disease was 161 (28%), 321 (56%), and 81 (14%), respectively. One hundred and sixty three of 569 (29%) required a total of 185 redo-HIFU procedures. Median follow-up was 46 (interquartile range 23-61) mo. Failure-free survival at 5 yr after first HIFU was 70% (95% confidence interval [CI]: 64-74). This was 87% (95% CI: 78-93), 63% (95% CI: 56-70), and 58% (95% CI: 32-77) for National Comprehensive Cancer Network low-, intermediate-, and high-risk groups, respectively. Fifty eight of 754 (7.7%) had one urinary tract infection, 22/574 (2.9%) a recurrent urinary tract infection, 22/754 (3%) epididymo-orchitis, 227/754 (30%) endoscopic interventions, 1/754 (0.13%) recto-urethral fistula, and 1/754 (0.13%) osteitis pubis. Of 206 known to be pad-free pre-HIFU, 183/206 (88%) remained pad free, and of 236 with good baseline erectile function, 91/236 (39%) maintained good function. The main limitation is lack of long-term data. CONCLUSIONS Whole-gland HIFU is a repeatable day-case treatment that confers low rates of urinary incontinence. Disease control at a median of just under 5 yr of follow-up demonstrates its potential as a treatment for nonmetastatic prostate cancer. Endoscopic interventions and erectile dysfunction rates are similar to other whole-gland treatments. PATIENT SUMMARY In this report we looked at the 5-yr outcomes following whole-gland high-intensity focused ultrasound treatment for prostate cancer and found that cancer control was acceptable with a low risk of urine leakage. However, risk of erectile dysfunction and further operations was similar to other whole-gland treatments like surgery and radiotherapy.
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Affiliation(s)
- Louise Dickinson
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Manit Arya
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK; Department of Urology, Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Naveed Afzal
- Department of Urology, Dorset County Hospital, Dorchester, UK
| | - Paul Cathcart
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Andrew Cornaby
- Department of Urology, Dorset County Hospital, Dorchester, UK
| | - Richard G Hindley
- Department of Urology, Basingstoke Hospital, Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
| | - Henry Lewi
- Department of Urology, Broomfield Hospital, Mid Essex NHS Trust, Chelmsford, UK
| | - Neil McCartan
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Caroline M Moore
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Senthil Nathan
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Chris Ogden
- Department of Academic Urology, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Raj Persad
- Department of Urology, North Bristol NHS Trust, Bristol, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Shraddha Weir
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Hashim U Ahmed
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK.
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21
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Valerio M, Anele C, Bott SRJ, Charman SC, van der Meulen J, El-Mahallawi H, Emara AM, Freeman A, Jameson C, Hindley RG, Montgomery BSI, Singh PB, Ahmed HU, Emberton M. The Prevalence of Clinically Significant Prostate Cancer According to Commonly Used Histological Thresholds in Men Undergoing Template Prostate Mapping Biopsies. J Urol 2015; 195:1403-1408. [PMID: 26626221 DOI: 10.1016/j.juro.2015.11.047] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2015] [Indexed: 12/14/2022]
Abstract
PURPOSE Transrectal prostate biopsies are inaccurate and, thus, the prevalence of clinically significant prostate cancer in men undergoing biopsy is unknown. We determined the ability of different histological thresholds to denote clinically significant cancer in men undergoing a more accurate biopsy, that of transperineal template prostate mapping. MATERIALS AND METHODS In this multicenter, cross-sectional cohort of men who underwent template prostate mapping biopsies between May 2006 and January 2012, 4 different thresholds of significance combining tumor grade and burden were used to measure the consequent variation with respect to the prevalence of clinically significant disease. RESULTS Of 1,203 men 17% (199) had no previous biopsy, 38% (455) had a prior negative transrectal ultrasound biopsy, 24% (289) were on active surveillance and 21% (260) were seeking risk stratification. Mean patient age was 63.5 years (SD 7.6) and median prostate specific antigen was 7.4 ng/ml (IQR 5.3-10.5). Overall 35% of the patients (424) had no cancer detected. The prevalence of clinically significant cancer varied between 14% and 83% according to the histological threshold used, in particular between 30% and 51% among men who had no previous biopsy, between 14% and 27% among men who had a prior negative biopsy, between 36% and 74% among men on active surveillance, and between 47% and 83% among men seeking risk stratification. CONCLUSIONS According to template prostate mapping biopsy between 1 in 2 and 1 in 3 men have prostate cancer that is histologically defined as clinically significant. This suggests that the commonly used thresholds may be set too low.
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Affiliation(s)
- M Valerio
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Urology, University College Hospitals NHS Foundation Trust, London, United Kingdom; Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - C Anele
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Urology, University College Hospitals NHS Foundation Trust, London, United Kingdom
| | - S R J Bott
- Department of Urology, Frimley Park Hospital NHS Foundation Trust, Frimley, United Kingdom
| | - S C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - J van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - H El-Mahallawi
- Department of Histopathology, Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, Hampshire, United Kingdom
| | - A M Emara
- Department of Urology, Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, Hampshire, United Kingdom; Department of Urology, Ain Shams University, Cairo, Egypt
| | - A Freeman
- Department of Histopathology, University College Hospital London, London, United Kingdom
| | - C Jameson
- Department of Histopathology, University College Hospital London, London, United Kingdom
| | - R G Hindley
- Department of Urology, Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, Hampshire, United Kingdom
| | - B S I Montgomery
- Department of Urology, Frimley Park Hospital NHS Foundation Trust, Frimley, United Kingdom
| | - P B Singh
- Department of Urology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - H U Ahmed
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Urology, University College Hospitals NHS Foundation Trust, London, United Kingdom
| | - M Emberton
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Urology, University College Hospitals NHS Foundation Trust, London, United Kingdom
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22
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Valerio M, Anele C, Charman SC, van der Meulen J, Freeman A, Jameson C, Singh PB, Emberton M, Ahmed HU. Transperineal template prostate-mapping biopsies: an evaluation of different protocols in the detection of clinically significant prostate cancer. BJU Int 2015; 118:384-90. [PMID: 26332050 DOI: 10.1111/bju.13306] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To determine whether modified transperineal template prostate-mapping (TTPM) biopsy protocols, altering the template or the biopsy density, have sensitivity and negative predictive value (NPV) equal to full 5-mm TTPM. PATIENTS AND METHODS Retrospective analysis of an institutional registry including treatment-naïve men undergoing 5-mm TTPM biopsy analysed in a 20-zone fashion. The value of three modified strategies was assessed by comparing the information provided by selected zones against full 5-mm TTPM. Strategy 1, did not consider the findings of anterior areas; strategies 2 and 3 simulated a reduced biopsy density by excluding intervening zones. A bootstrapping technique was used to calculate reliable estimates of sensitivity and NPV of these three strategies for the detection of clinically significant disease (maximum cancer core length ≥4 mm and/or Gleason score ≥3 + 4). RESULTS In all, 391 men with a median (interquartile range, IQR) age of 62 (58-67) years were included. The median (IQR) PSA level and PSA density were 6.9 (4.8-10) ng/mL and 0.17 (IQR 0.12-0.25) ng/mL/mL, respectively. A median (IQR) of 6 (2-9) cores out of 48 (33-63) taken per man were positive for prostate cancer. No cancer was detected in 67 men (17%), whilst low-, intermediate- and high-risk disease was identified in 78 (20%), 80 (21%), and 166 (42%), respectively. Strategy 1, 2 and 3 had sensitivities of 78% [95% confidence interval (CI) 73-84%], 85% (95% CI 80-90%) and 84% (95% CI 79-89%), respectively. The NPVs of the three strategies were 73% (95% CI 67-80%), 80% (95% CI 74-86%) and 79% (95% CI 72-84%), respectively. CONCLUSION Altering the template or decreasing sampling density has a substantial negative impact on the ability of TTPM biopsy to exclude clinically significant disease. This should be considered when modified TTPM biopsy strategies are used to select men for tissue-preserving approaches, and when modified TTPM are used to validate new diagnostic tests.
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Affiliation(s)
- Massimo Valerio
- Division of Surgery and Interventional Science, University College Hospitals NHS Foundation Trust, London, UK.,Department of Urology, University College Hospitals NHS Foundation Trust, London, UK.,Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Chukwuemeka Anele
- Division of Surgery and Interventional Science, University College Hospitals NHS Foundation Trust, London, UK.,Department of Urology, University College Hospitals NHS Foundation Trust, London, UK
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Alex Freeman
- Department of Histopathology, University College Hospitals NHS Foundation Trust, London, UK
| | - Charles Jameson
- Department of Histopathology, University College Hospitals NHS Foundation Trust, London, UK
| | - Paras B Singh
- Department of Urology, Royal Free Hospital NHS Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College Hospitals NHS Foundation Trust, London, UK.,Department of Urology, University College Hospitals NHS Foundation Trust, London, UK
| | - Hashim U Ahmed
- Division of Surgery and Interventional Science, University College Hospitals NHS Foundation Trust, London, UK.,Department of Urology, University College Hospitals NHS Foundation Trust, London, UK
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23
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Anastasiadis E, Charman SC, Arumainayagam N, Sohaib AS, Allen C, Freeman A, Emberton M, Ahmed HU. What Burden of Prostate Cancer Can Radiologists Rule Out on Multiparametric Magnetic Resonance Imaging? A Sensitivity Analysis Based on Varying the Target Condition in Template Prostate Mapping Biopsies. Urology 2015; 86:544-51. [PMID: 26253041 DOI: 10.1016/j.urology.2015.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 04/12/2015] [Accepted: 05/03/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the minimum disease burden of prostate cancer at which multiparametric magnetic resonance imaging (MRI) optimally performs. METHODS Between 2006 and 2008, 64 men underwent multiparametric MRI imaging (index test) followed by template prostate mapping biopsy (reference test). Three radiologists independently reported each quadrant of every prostate on a scale of 1 to 5: highly likely benign, likely benign, equivocal, likely malignant, highly likely malignant (≥3 or ≥4 was considered positive). There were 256 prostate sectors; bootstrapping adjustment was used to account for nonindependence. The target condition indicating cancer on biopsies was varied by changing the maximum cancer core length (MCCL) and total cancer core length (TCCL) within each sector from 1 mm to 10 mm. The sensitivity, specificity, and positive (PPVs) and negative predictive values (PPVs) were calculated for each MCCL and TCCL. Gleason ≤3+3 and Gleason ≥3+4 cancers were analyzed separately. RESULTS Mean age was 62 years (range, 40-76 years), and mean prostate-specific antigen level was 8.2 μg/L (range, 2.1-43 μg/L). Fifty percent of quadrants (127 of 256) had prostate cancer, of which 65% (83 of 127) were Gleason ≤3+3. For Gleason ≤3+3, multiparametric MRI had an NPV of ≥95% at an MCCL of ≥5 mm and at a TCCL of ≥7 mm (MRI score ≥3). For Gleason ≥3+4, an NPV of ≥95% was seen at an MCCL of ≥5 mm (MRI score ≥3) and TCCL ≥6 mm. CONCLUSION Multiparametric MRI may allow areas of the prostate which test negative to avoid biopsy. Whether multiparametric MRI can be used as a "triage" test before the first biopsy requires results from ongoing prospective validating cohort studies.
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Affiliation(s)
- Eleni Anastasiadis
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom.
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nimalan Arumainayagam
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Aslam S Sohaib
- Department of Radiology, The Royal Marsden Hospital, London, United Kingdom
| | - Clare Allen
- Department of Imaging, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Alex Freeman
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Urology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Hashim U Ahmed
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Urology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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24
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Tovikkai C, Charman SC, Praseedom RK, Gimson AE, van der Meulen J. Time-varying impact of comorbidities on mortality after liver transplantation: a national cohort study using linked clinical and administrative data. BMJ Open 2015; 5:e006971. [PMID: 25976762 PMCID: PMC4442248 DOI: 10.1136/bmjopen-2014-006971] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE We assessed the impact of comorbidity on mortality in three periods after liver transplantation (first 90 days, 90 days-5 years and 5-10 years). DESIGN Prospective cohort study using records from the UK Liver Transplant Audit (UKLTA) linked to Hospital Episode Statistics (HES), an administrative database of hospital admissions in the English National Health Service (NHS). Comorbidities relevant for liver transplantation were identified from the 10th revision of the International Classification of Diseases (ICD-10) codes in HES records of admissions in the year preceding their operation. Multivariable Cox regression was used to estimate HRs for three different time periods after liver transplantation. SETTING All liver transplant centres in the NHS hospitals in England. PARTICIPANTS Adults who received a first elective liver transplant between April 1997 and March 2010 in the linked UKLTA-HES database. OUTCOMES Patient mortality in three different time periods after transplantation. RESULTS Among 3837 recipients, 45.1% had comorbidities. Recipients with cardiovascular disease had statistically significantly higher mortality in all three periods after transplantation (first 90 days: HR=2.0; 95% CI 1.4 to 2.9, 90 days-5 years: 1.6; 1.2 to 2.2, beyond 5 years: 2.8; 1.7 to 4.4). Prior congestive cardiac failure (3.2; 2.1 to 4.9) significantly increased mortality only in the first 90 days. History of non-hepatic malignancy appeared to increase risk over all periods, but significantly only in the first 90 days (1.9; 1.0 to 3.6). A diagnosis of connective tissue disease, dementia, diabetes, chronic pulmonary and renal disease did not have a significant impact on mortality in any period. CONCLUSIONS The impact of comorbidities present at the time of transplantation changes with time after transplantation. Renal disease, pulmonary disease and diabetes had no impact on mortality in contrast to previous reports.
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Affiliation(s)
- Chutwichai Tovikkai
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Susan C Charman
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Raaj K Praseedom
- Department of Surgery, University of Cambridge, Cambridge, UK
- Liver Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alexander E Gimson
- Liver Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jan van der Meulen
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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25
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Withington JM, Charman SC, Armitage JN, Cromwell D, Finch WD, Wiseman OJ, Irving S, Glass J, Burgess NA. Hospital Volume Does Not Influence the Safety of Percutaneous Nephrolithotomy in England: A Population-Based Cohort Study. J Endourol 2015; 29:899-906. [PMID: 25778687 DOI: 10.1089/end.2015.0007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE This study aims to investigate the relationship between hospital case volume and safety-related outcomes after percutaneous nephrolithotomy (PCNL) within the English National Health Service (NHS). PATIENTS AND METHODS The study used the Hospital Episode Statistics (HES) database, a routine administrative database, recording information on operations, comorbidity, and outcomes for all NHS hospital admissions in England. Records for all patients undergoing an initial PCNL between April 1, 2006 and March 31, 2012 were extracted. NHS trusts were divided into low-, medium-, and high-volume groups, according to the average annual number of PCNLs performed. We used multiple regression analyses to examine the associations between hospital volume and outcomes incorporating risk adjustment for sex, age, comorbidity, and hospital teaching status. Postoperative outcomes included: Emergency readmission, infection, and hemorrhage. Mean length of stay was also measured. RESULTS There were 7661 index elective PCNL procedures performed in 163 hospital trusts, between April 2006 and March 2012. There were 2459 patients who underwent PCNL in the 116 units performing fewer than 10 PCNL procedures per year; 2643 patients in the 37 units performing 10 to 19 procedures per year; and 2459 patients in the 9 hospitals performing more than 20 procedures per year. For low-, medium-, and high-volume trusts, there was little variation in the rates of emergency readmission (L 9.7%, M 9.3%, H 8.4%), infection (3.0%, 4.2%, 3.8%), or hemorrhage (1.3%, 1.5%, 1.5%), and there was no statistical evidence that volume was associated with adjusted outcomes. Mean length of stay was slightly shorter in the medium- (5.0 days) and high-volume (5.0) groups compared with the low-volume group (5.3). The effect remained statistically significant after adjusted for confounding. CONCLUSION Hospital volume was not associated with emergency readmission, infection, or hemorrhage. Length of stay appears to be shorter in higher volume units.
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Affiliation(s)
- John M Withington
- 1 Clinical Effectiveness Unit, Royal College of Surgeons , London, United Kingdom
| | - Susan C Charman
- 2 Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine , London, United Kingdom
| | - James N Armitage
- 3 Department of Urology, Cambridge University Hospitals NHS Foundation Trust , Cambridge, United Kingdom
| | - David Cromwell
- 2 Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine , London, United Kingdom
| | - William D Finch
- 4 Department of Urology, Norfolk and Norwich University Hospital NHS Foundation Trust , Norwich, United Kingdom
| | - Oliver J Wiseman
- 5 Department of Urology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Stuart Irving
- 4 Department of Urology, Norfolk and Norwich University Hospital NHS Foundation Trust , Norwich, United Kingdom
| | - Jonathan Glass
- 6 Department of Urology, Guy's and St Thomas' Hospitals NHS Trust , London, United Kingdom
| | - Neil A Burgess
- 4 Department of Urology, Norfolk and Norwich University Hospital NHS Foundation Trust , Norwich, United Kingdom
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Abd-Alazeez M, Kirkham A, Ahmed HU, Arya M, Anastasiadis E, Charman SC, Freeman A, Emberton M. Performance of multiparametric MRI in men at risk of prostate cancer before the first biopsy: a paired validating cohort study using template prostate mapping biopsies as the reference standard. Prostate Cancer Prostatic Dis 2014; 17:40-6. [PMID: 24126797 PMCID: PMC3954968 DOI: 10.1038/pcan.2013.43] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [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: 06/16/2013] [Revised: 07/23/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Multiparametric magnetic resonance imaging (mpMRI) has the potential to serve as a non-invasive triage test for men at risk of prostate cancer. Our objective was to determine the performance characteristics of mpMRI in men at risk before the first biopsy using 5 mm template prostate mapping (TPM) as the reference standard. METHODS One hundred and twenty-nine consecutive men with clinical suspicion of prostate cancer, who had no prior biopsy, underwent mpMRI (T1/T2-weighted, diffusion-weighting, dynamic contrast enhancement) followed by TPM. The primary analysis used were as follows: (a) radiological scores of suspicion of ≥3 attributed from a five-point ordinal scale, (b) a target condition on TPM of any Gleason pattern ≥4 and/or a maximum cancer core length of ≥4 mm and (c) two sectors of analysis per prostate (right and left prostate halves). Secondary analyses evaluated the impact of changing the mpMRI score threshold to ≥4 and varying the target definition for clinical significance. RESULTS One hundred and forty-one out of 258 (55%) sectors of analysis showed 'any cancer' and 77/258 (30%) had the target histological condition for the purpose of deriving the primary outcome. Median (with range) for age, PSA, gland volume and number of biopsies taken were 62 years (41-82), 5.8 ng ml(-1) (1.2-20), 40 ml (16-137) and 41 cores (20-93), respectively. For the primary outcome sensitivity, specificity, positive and negative predictive values and area under the receiver-operating curve (with 95% confidence intervals) were 94% (88-99%), 23% (17-29%), 34% (28-40%), 89% (79-98%) and 0.72 (0.65-0.79), respectively. CONCLUSIONS MpMRI demonstrated encouraging diagnostic performance characteristics in detecting and ruling out clinically significant prostate cancer in men at risk, who were biopsy naive.
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Affiliation(s)
- Mohamed Abd-Alazeez
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alex Kirkham
- Department of Radiology, University College Hospitals NHS Foundation Trust, London, UK
| | - Hashim U. Ahmed
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Manit Arya
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
- Barts Cancer Institute
| | - Eleni Anastasiadis
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Susan C. Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine
| | - Alex Freeman
- Department of Histopathology, University College Hospitals NHS Foundation Trust, London, UK
| | - Mark Emberton
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
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Simmons LAM, Ahmed HU, Moore CM, Punwani S, Freeman A, Hu Y, Barratt D, Charman SC, Van der Meulen J, Emberton M. The PICTURE study -- prostate imaging (multi-parametric MRI and Prostate HistoScanning™) compared to transperineal ultrasound guided biopsy for significant prostate cancer risk evaluation. Contemp Clin Trials 2013; 37:69-83. [PMID: 24291455 DOI: 10.1016/j.cct.2013.11.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 11/14/2013] [Accepted: 11/19/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The primary objective of the PICTURE study is to assess the negative predictive value of multi-parametric MRI (mp-MRI) and Prostate HistoScanning™ (PHS) in ruling-out clinically significant prostate cancer. PATIENTS AND METHODS PICTURE is a prospective diagnostic validating cohort study conforming to level 1 evidence. PICTURE will assess the diagnostic performance of multi-parametric Magnetic Resonance Imaging (mp-MRI) and Prostate HistoScanning™ (PHS) ultrasound. PICTURE will involve validating both index tests against a reference test, transperineal Template Prostate Mapping (TPM) biopsies, which can be applied in all men under evaluation. Men will be blinded to the index test results and both index tests will be reported prospectively prior to the biopsies being taken to ensure reporter blinding. Paired analysis of each of the index tests to the reference test will be done at patient level. Those men with an imaging lesion will undergo targeted biopsies to assess the clinical utility of sampling only suspicious areas. The study is powered to assess the negative predictive value of these imaging modalities in ruling-out clinically significant prostate cancer. DISCUSSION The PICTURE study aims to assess the performance characteristics of two imaging modalities (mp-MRI and Prostate HistoScanning) for their utility in the prostate cancer pathway. PICTURE aims to identify if either imaging test may be useful for ruling out clinically significant disease in men under investigation, and also to examine if either imaging modality is useful for the detection of disease. Recruitment is underway and expected to complete in 2014.
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Affiliation(s)
- Lucy A M Simmons
- Division of Surgery and Interventional Science, University College London, UK.
| | - Hashim Uddin Ahmed
- Division of Surgery and Interventional Science, University College London, UK
| | - Caroline M Moore
- Division of Surgery and Interventional Science, University College London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospitals, UK
| | - Alex Freeman
- Department of Pathology, University College London Hospitals, UK
| | - Yipeng Hu
- Centre for Medical Imaging and Computing, University College London, UK
| | - Dean Barratt
- Centre for Medical Imaging and Computing, University College London, UK
| | | | | | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, UK
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Varsani H, Charman SC, Li CK, Marie SKN, Amato AA, Banwell B, Bove KE, Corse AM, Emslie-Smith AM, Jacques TS, Lundberg IE, Minetti C, Nennesmo I, Rushing EJ, Sallum AME, Sewry C, Pilkington CA, Holton JL, Wedderburn LR. Validation of a score tool for measurement of histological severity in juvenile dermatomyositis and association with clinical severity of disease. Ann Rheum Dis 2013; 74:204-10. [PMID: 24064003 PMCID: PMC4283618 DOI: 10.1136/annrheumdis-2013-203396] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [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] [Indexed: 11/28/2022]
Abstract
Objectives To study muscle biopsy tissue from patients with juvenile dermatomyositis (JDM) in order to test the reliability of a score tool designed to quantify the severity of histological abnormalities when applied to biceps humeri in addition to quadriceps femoris. Additionally, to evaluate whether elements of the tool correlate with clinical measures of disease severity. Methods 55 patients with JDM with muscle biopsy tissue and clinical data available were included. Biopsy samples (33 quadriceps, 22 biceps) were prepared and stained using standardised protocols. A Latin square design was used by the International Juvenile Dermatomyositis Biopsy Consensus Group to score cases using our previously published score tool. Reliability was assessed by intraclass correlation coefficient (ICC) and scorer agreement (α) by assessing variation in scorers’ ratings. Scores from the most reliable tool items correlated with clinical measures of disease activity at the time of biopsy. Results Inter- and intraobserver agreement was good or high for many tool items, including overall assessment of severity using a Visual Analogue Scale. The tool functioned equally well on biceps and quadriceps samples. A modified tool using the most reliable score items showed good correlation with measures of disease activity. Conclusions The JDM biopsy score tool has high inter- and intraobserver agreement and can be used on both biceps and quadriceps muscle tissue. Importantly, the modified tool correlates well with clinical measures of disease activity. We propose that standardised assessment of muscle biopsy tissue should be considered in diagnostic investigation and clinical trials in JDM.
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Affiliation(s)
- Hemlata Varsani
- Rheumatology Unit, UCL Institute of Child Health, London, UK
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Charles K Li
- Rheumatology Unit, UCL Institute of Child Health, London, UK
| | - Suely K N Marie
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brasil
| | - Anthony A Amato
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brenda Banwell
- Department of Neurology, Children's Hospital of Philadelphia University of Pennsylvania, Philadelphia, Philadelphia, USA
| | - Kevin E Bove
- Department of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrea M Corse
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Thomas S Jacques
- Neural Development Unit, Institute of Child Health UCL, London, UK
| | - Ingrid E Lundberg
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Carlo Minetti
- Neuromuscular Disease Unit, Gaslini Institute, Genoa, Italy
| | - Inger Nennesmo
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Adriana M E Sallum
- Pediatric Rheumatology Unit, Department of Pediatrics, School of Medicine, University of São Paulo, São Paulo, Brasil
| | - Caroline Sewry
- Dubowitz Neuromuscular Centre, Institute of Child Health UCL, London, UK
| | | | - Janice L Holton
- Department of Molecular Neuroscience, MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology, UCL, London, UK
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Abd-Alazeez M, Ahmed HU, Arya M, Charman SC, Anastasiadis E, Freeman A, Emberton M, Kirkham A. The accuracy of multiparametric MRI in men with negative biopsy and elevated PSA level--can it rule out clinically significant prostate cancer? Urol Oncol 2013; 32:45.e17-22. [PMID: 24055430 PMCID: PMC4082533 DOI: 10.1016/j.urolonc.2013.06.007] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 05/12/2013] [Accepted: 06/13/2013] [Indexed: 11/15/2022]
Abstract
Purpose To assess the performance of multiparametric magnetic resonance imaging (mp-MRI) in patients with previous negative transrectal ultrasound (TRUS) guided prostate biopsy. Materials and methods Fifty-four patients with at least 1 previous negative TRUS prostate biopsy underwent mp-MRI in the form of T2-weighted, diffusion-weighted, and dynamic contrast-enhanced imaging. This was followed by transperineal template systematic prostate biopsies. Analysis was done based on 2 sectors per prostate, right and left (108 sectors out of 54 prostates). mp-MRI was scored using an ordinal scale 1 to 5 based on the suspicion of the presence of clinically significant disease. We used 6 different definitions for clinically significant disease and tested the performance of mp-MRI at each single definition. Results Median age was 64 (range, 39–75), median PSA level was 10 (range, 2–23), and median number of biopsies was 45 (range, 21–137). Cancer of any volume and any grade was detected in 34 of 54 (63%) patients. mp-MRI accuracy at detection of clinically significant cancer using University College London (UCL) definition 2 (any Gleason score of 4 or maximum cancer core length of ≥4 mm or both) showed sensitivity of 76%, specificity of 42%, positive predictive value of 38%, and negative predictive value of 79%. For a different definition of significant tumor (UCL definition 1; dominant Gleason score 4 or maximum cancer core length ≥6 mm or both), the sensitivity was 90%, specificity 42%, positive predictive value 26%, and negative predictive value 95%. Conclusions mp-MRI showed good performance at both detection and ruling out clinically significant disease, according to the definition used. mp-MRI can then be used as a triage test in the population with persistently elevated or rising PSA levels to select patients that can avoid unnecessary prostate biopsy.
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Affiliation(s)
- Mohamed Abd-Alazeez
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Urology, Faculty of medicine, Fayoum University, Fayoum, Egypt.
| | - Hashim U Ahmed
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
| | - Manit Arya
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK; Barts Cancer Institute, Queen Mary, University of London, London, UK
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine
| | - Eleni Anastasiadis
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Alex Freeman
- Department of Histopathology, University College Hospitals NHS Foundation Trust, London, UK
| | - Mark Emberton
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
| | - Alex Kirkham
- Department of Radiology, University College Hospitals NHS Foundation Trust, London, UK
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Callaghan CJ, Charman SC, Muiesan P, Powell JJ, Gimson AE, van der Meulen JHP. Outcomes of transplantation of livers from donation after circulatory death donors in the UK: a cohort study. BMJ Open 2013; 3:e003287. [PMID: 24002984 PMCID: PMC3773642 DOI: 10.1136/bmjopen-2013-003287] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Outcomes of liver transplantations from donation after circulatory death (DCD) donors may be inferior to those achieved with donation after brain death (DBD) donors. The impact of using DCD donors is likely to depend on specific national practices. We compared risk-adjusted graft loss and recipient mortality after transplantation of DCD and DBD livers in the UK. DESIGN Prospective cohort study. Multivariable Cox regression and propensity score matching were used to estimate risk-adjusted HR. SETTING 7 liver transplant centres in the National Health Service (NHS) hospitals in England and Scotland. PARTICIPANTS Adults who received a first elective liver transplant between January 2005 and December 2010 who were identified in the UK Liver Transplant Audit. INTERVENTIONS Transplantation of DCD and DBD livers. OUTCOMES Graft loss and recipient mortality. RESULTS In total, 2572 liver transplants were identified with 352 (14%) from DCD donors. 3-year graft loss (95% CI) was higher with DCD livers (27.3%, 21.8% to 33.9%) than with DBD livers (18.2%, 16.4% to 20.2%). After adjustment with regression, HR for graft loss was 2.3 (1.7 to 3.0). Similarly, 3-year mortality was higher with DCD livers (19.4%, 14.5% to 25.6%) than with DBD livers (14.1%, 12.5% to 16.0%) with an adjusted HR of 2.0 (1.4 to 2.8). Propensity score matching gave similar results. Centre-specific adjusted HRs for graft loss and recipient mortality seemed to differ among transplant centres, although statistical evidence is weak (p value for interaction 0.08 and 0.24, respectively). CONCLUSIONS Graft loss and recipient mortality were about twice as high with DCD livers as with DBD livers in the UK. Outcomes after DCD liver transplantation may vary between centres. These results should inform policies for the use of DCD livers.
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Affiliation(s)
| | - Susan C Charman
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Paolo Muiesan
- Department of Liver Transplantation and Hepatopancreatobiliary Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - James J Powell
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Jan H P van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Kasivisvanathan V, Dufour R, Moore CM, Ahmed HU, Abd-Alazeez M, Charman SC, Freeman A, Allen C, Kirkham A, van der Meulen J, Emberton M. Transperineal magnetic resonance image targeted prostate biopsy versus transperineal template prostate biopsy in the detection of clinically significant prostate cancer. J Urol 2012; 189:860-6. [PMID: 23063807 DOI: 10.1016/j.juro.2012.10.009] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2012] [Indexed: 12/17/2022]
Abstract
PURPOSE Multiparametric magnetic resonance imaging can be used to guide prostate biopsy by targeting biopsies to areas in the prostate at high risk for cancer. We compared the detection of clinically significant and insignificant cancer by transperineal magnetic resonance imaging targeted biopsy and transperineal template guided prostate biopsy. MATERIALS AND METHODS A total of 182 men with a lesion suspicious for cancer on multiparametric magnetic resonance imaging underwent transperineal magnetic resonance imaging targeted biopsy using a cognitive registration technique, followed by systematic transperineal template guided prostate biopsy. The primary outcome was the detection rate of clinically significant prostate cancer. Clinical significance was defined using maximum cancer core length 4 mm or greater and/or Gleason grade 3 + 4 or greater (University College London definition 2). We secondarily evaluated other commonly used thresholds of clinically significant disease, including maximum cancer core length 6 mm or greater and/or Gleason grade 4 + 3 or greater, maximum cancer core length 3 mm or greater and/or Gleason grade 3 + 4 or greater, and maximum cancer core length 2 or greater mm and/or Gleason grade 3 + 4 or greater. Strategies were statistically compared with the McNemar test. RESULTS Mean ± SD patient age was 63.3 ± 7.2 years. Median prostate specific antigen was 6.7 ng/ml (IQR 4.7-10.0). Clinically significant cancer was detected by magnetic resonance imaging targeted biopsy and template guided prostate biopsy in 103 (57%) and 113 of the 182 men (62%) (p = 0.174), and clinically insignificant cancer was detected in 17 (9.3%) and 31 (17.0%), respectively (p = 0.024). CONCLUSIONS Prostate biopsy targeted to suspicious lesions on multiparametric magnetic resonance imaging has encouraging rates of detection of clinically significant cancer while also decreasing the detection rate of clinically insignificant cancer. This is achieved with fewer biopsy cores than for systematic template guided biopsy. Further prospective, multicenter, comparative trials of the performance of targeting strategies are needed to consider magnetic resonance imaging targeted biopsy an alternative to conventional systematic biopsy.
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Affiliation(s)
- Veeru Kasivisvanathan
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom.
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Jameson SS, Baker PN, Charman SC, Deehan DJ, Reed MR, Gregg PJ, Van der Meulen JH. The effect of aspirin and low-molecular-weight heparin on venous thromboembolism after knee replacement: a non-randomised comparison using National Joint Registry Data. ACTA ACUST UNITED AC 2012; 94:914-8. [PMID: 22733945 DOI: 10.1302/0301-620x.94b7.29129] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We compared thromboembolic events, major haemorrhage and death after knee replacement in patients receiving either aspirin or low-molecular-weight heparin (LMWH). Data from the National Joint Registry for England and Wales were linked to an administrative database of hospital admissions in the English National Health Service. A total of 156,798 patients between April 2003 and September 2008 were included and followed for 90 days. Multivariable risk modelling was used to estimate odds ratios adjusted for baseline risk factors (AOR). An AOR < 1 indicates that risk rates are lower with LMWH than with aspirin. In all, 36,159 patients (23.1%) were prescribed aspirin and 120,639 patients (76.9%) were prescribed LMWH. We found no statistically significant differences between the aspirin and LMWH groups in the rate of pulmonary embolism (0.49% vs 0.45%, AOR 0.88 (95% confidence interval (CI) 0.74 to 1.05); p = 0.16), 90-day mortality (0.39% vs 0.45%, AOR 1.13 (95% CI 0.94 to 1.37); p = 0.19) or major haemorrhage (0.37% vs 0.39%, AOR 1.01 (95% CI 0.83 to 1.22); p = 0.94). There was a significantly greater likelihood of needing to return to theatre in the aspirin group (0.26% vs 0.19%, AOR 0.73 (95% CI 0.58 to 0.94); p = 0.01). Between patients receiving LMWH or aspirin there was only a small difference in the risk of pulmonary embolism, 90-day mortality and major haemorrhage. These results should be considered when the existing guidelines for thromboprophylaxis after knee replacement are reviewed.
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Affiliation(s)
- S S Jameson
- The National Joint Registry for England and Wales, 15-17 Tavistock Place, London WC1H 9SH, UK
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Stafford GH, Charman SC, Borroff MJ, Newell C, Tucker JK. Total hip replacement for the treatment of acute femoral neck fractures: results from the National Joint Registry of England and Wales at 3-5 years after surgery. Ann R Coll Surg Engl 2012; 94:193-8. [PMID: 22507726 DOI: 10.1308/003588412x13171221589720] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This paper describes, for the first time, the outcomes of patients undergoing total hip replacement for acute fractured neck of femur (#NOF) as recorded by the National Joint Registry of England and Wales (NJR). METHODS In the NJR we identified 1,302 of 157,232 Hospital Episode Statistics linked patients who had been recorded as having a total hip replacement for acute #NOF between April 2003 and November 2008. RESULTS The revision rate at five years for fully uncemented components was 4.1% (95% confidence interval [CI]: 2.2-7.3%), for hybrid it was 2.2% (95% CI: 0.9%-5.3%) and for fully cemented components 0.9% (95% CI: 0.4-2.0%). Five-year revision rates were increased for those whose operations were performed via a posterior versus a lateral approach. The Kaplan-Meier estimate of 30-day mortality was 1.4% (95% CI: 1.0-2.4%), which is over double the 30-day mortality rate for total hip replacement identified by the Office for National Statistics. The mean length of stay was also increased for those undergoing total hip replacements for #NOF compared with non-emergency indications. CONCLUSIONS Our data suggest that total hip replacements for acute #NOF give comparable results with total hip replacements for other indications.
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Affiliation(s)
- G H Stafford
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London WC2A 3PE, UK.
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Jameson SS, Charman SC, Gregg PJ, Reed MR, van der Meulen JH. The effect of aspirin and low-molecular-weight heparin on venous thromboembolism after hip replacement: a non-randomised comparison from information in the National Joint Registry. ACTA ACUST UNITED AC 2012; 93:1465-70. [PMID: 22058295 DOI: 10.1302/0301-620x.93b11.27622] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [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
We compared thromboembolic events, major haemorrhage and death after total hip replacement in patients receiving either aspirin or low-molecular-weight heparin (LMWH). We analysed data from the National Joint Registry for England and Wales linked to an administrative database of hospital admissions in the English National Health Service. A total of 108,584 patients operated on between April 2003 and September 2008 were included and followed up for 90 days. Multivariable risk modelling and propensity score matching were used to estimate odds ratios (OR) adjusted for baseline risk factors. An OR < 1 indicates that rates are lower with LMWH than with aspirin. In all, 21.1% of patients were prescribed aspirin and 78.9% LMWH. Without adjustment, we found no statistically significant differences. The rate of pulmonary embolism was 0.68% in both groups and 90-day mortality was 0.65% with aspirin and 0.61% with LMWH (OR 0.93; 95% CI 0.77 to 1.11). With risk adjustment, the difference in mortality increased (OR 0.84; 95% CI 0.69 to 1.01). With propensity score matching the mortality difference increased even further to 0.65% with aspirin and 0.51% with LMWH (OR 0.77; 95% CI 0.61 to 0.98). These results should be considered when the conflicting recommendations of existing guidelines for thromboprophylaxis after hip replacement are being addressed.
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Affiliation(s)
- S S Jameson
- South Tees Hospitals Foundation Trust, James Cook Hospital, Marton Road, Middlesbrough TS4 3BW, UK
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Bream E, Charman SC, Clift B, Murray D, Black N. Relationship between patients' and clinicians' assessments of health status before and after knee arthroplasty. Qual Saf Health Care 2010; 19:e6. [PMID: 20595715 DOI: 10.1136/qshc.2008.031310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The use of patient reported outcome measures (PROMs) for four elective operations is mandatory in the English NHS from April 2009. In view of some scepticism by some clinicians as to the validity of PROMs, our aim was to explore the relationship between patients' and clinicians' reports of health status before and after knee arthroplasty. METHODS A secondary analysis of linked data from the Knee Arthroplasty Trial (patients' reports using the Oxford Knee Score) and the Tayside Arthroplasty Audit (clinicians' reports using the American Knee Society Score--Knee Score and Functional Score) was carried out. Correlations of scores were obtained for 284 patients before and 226 patients after surgery. RESULTS There was a moderately strong correlation between patients' and clinicians' views 1 year after surgery: Oxford Knee Score (OKS) versus American Knee Society Scores (AKSS) Knee Score r = -0.64; OKS versus AKSS Functional Score r = -0.44. Before surgery, the correlation between the OKS and the AKSS Functional Score was also moderate (r = -0.55) but was weak with the Knee Score (r = -0.23). There was no systematic direction to the differences between patients' and clinicians' assessments; patients were just as likely to report better health than their clinician as to report worse health. DISCUSSION Patients' postoperative assessments following knee arthroplasty, as regards their symptoms and disability, are practical to collect and can make a meaningful and useful contribution in routine use. In view of the advantages of collecting data on symptoms and disability directly from patients-lower cost, higher response rates, avoidance of systematic biases-confirmation of a moderately strong association with clinicians' views offers further reassurance for the routine use of PROMs, at least with knee arthroplasty.
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Affiliation(s)
- Elizabeth Bream
- Department of Public Health and Health Policy, NHS Lothian, Deaconess House, 148 The Pleasance, Edinburgh EH8 9RS, UK.
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Taylor SA, Charman SC, Lefere P, McFarland EG, Paulson EK, Yee J, Aslam R, Barlow JM, Gupta A, Kim DH, Miller CM, Halligan S. CT Colonography: Investigation of the Optimum Reader Paradigm by Using Computer-aided Detection Software. Radiology 2008; 246:463-71. [DOI: 10.1148/radiol.2461070190] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wedderburn LR, Varsani H, Li CKC, Newton KR, Amato AA, Banwell B, Bove KE, Corse AM, Emslie-Smith A, Harding B, Hoogendijk J, Lundberg IE, Marie S, Minetti C, Nennesmo I, Rushing EJ, Sewry C, Charman SC, Pilkington CA, Holton JL. International consensus on a proposed score system for muscle biopsy evaluation in patients with juvenile dermatomyositis: A tool for potential use in clinical trials. ACTA ACUST UNITED AC 2007; 57:1192-201. [PMID: 17907237 DOI: 10.1002/art.23012] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [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: 11/08/2022]
Abstract
OBJECTIVE To devise and test a system with which to evaluate abnormalities on muscle biopsy samples obtained from children diagnosed with juvenile dermatomyositis (DM). METHODS We established an International Consensus Group on Juvenile DM Biopsy and carried out 2 phases of consensus process and scoring workshops. Biopsy sections (n = 33) were stained by standard methods. The scoring tool was based on 4 domains of change: inflammatory, vascular, muscle fiber, and connective tissue. Using a Latin square design, biopsy samples were scored by 11 experts for items in each domain, and for a global abnormality measure using a 10-cm visual analog score (VAS 0-10). The tool's reliability was assessed using an intraclass correlation coefficient (ICC) and scorer agreement (alpha) by determining variation in scorers' ratings. RESULTS There was good agreement in many items of the tool, and several items refined between the meetings improved in reliability and/or agreement. The inflammatory and muscle fiber domains had the highest reliability and agreement. The overall VAS score for abnormality had high agreement and reliability, reaching an ICC of 0.863 at the second consensus meeting. CONCLUSION We propose a provisional scoring system to measure abnormalities on muscle biopsy samples obtained from children with juvenile DM. This system needs to be validated, and then could be used in prospective studies to test which features of muscle pathology are prognostic of disease course or outcome. We suggest that the process we used could be a template for developing similar systems in other forms of myositis.
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Chambers SA, Charman SC, Rahman A, Isenberg DA. Development of additional autoimmune diseases in a multiethnic cohort of patients with systemic lupus erythematosus with reference to damage and mortality. Ann Rheum Dis 2007; 66:1173-7. [PMID: 17213253 PMCID: PMC1955129 DOI: 10.1136/ard.2006.062984] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [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: 11/03/2022]
Abstract
OBJECTIVES To determine the prevalence of other autoimmune diseases (AID) in black, Caucasian and South Asian patients with systemic lupus erythematosus (SLE) compared with the prevalence of these AID in the UK population, and to assess the impact of these additional AID on damage scores and mortality. METHODS The prevalence and chronology of development of additional AID in SLE patients was determined by case note review. Comparisons were made with prevalence data for AID in the general UK population. The impact of additional AID on mortality and damage scores at up to 10 years was determined in the index cases (patients who developed another AID either in the same year or within 5 years of onset of SLE) compared with controls matched for sex, age, ethnicity and year of onset of SLE. RESULTS There was no significant difference in the total number of AID that developed in patients from each ethnic group but differences in the frequency of some AID were noted. Mortality and damage scores were worse at 5 years in the study cases than the controls, particularly in the peripheral vascular category. CONCLUSION Patients with SLE might develop other AID that could complicate management of SLE by having an adverse impact on damage scores and mortality.
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Affiliation(s)
- S A Chambers
- MRCP, The Centre for Rheumatology, University College London Hospital, 250 Euston Road, 3rd Floor Central, London NW1 2PG, UK.
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Win T, Jackson A, Groves AM, Sharples LD, Charman SC, Laroche CM. Comparison of shuttle walk with measured peak oxygen consumption in patients with operable lung cancer. Thorax 2005; 61:57-60. [PMID: 16244091 PMCID: PMC2080711 DOI: 10.1136/thx.2005.043547] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [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: 01/08/2023]
Abstract
BACKGROUND The relationship between the shuttle walk test and peak oxygen consumption in patients with lung cancer has not previously been reported. A study was undertaken to examine this relationship in patients referred for lung cancer surgery to test the hypothesis that the shuttle walk test would be useful in this clinical setting. METHODS 125 consecutive patients with potentially operable lung cancer were prospectively recruited. Each performed same day shuttle walking and treadmill walking tests. RESULTS Shuttle walk distances ranged from 104 m to 1020 m and peak oxygen consumption ranged from 9 to 35 ml/kg/min. The shuttle walk distance significantly correlated with peak oxygen consumption (r = 0.67, p<0.001). All 55 patients who achieved more than 400 m on the shuttle test had a peak oxygen consumption of at least 15 ml/kg/min. Seventy of 125 patients failed to achieve 400 m on the shuttle walk test; in 22 of these the peak oxygen consumption was less than 15 ml/kg/min. Nine of 17 patients who achieved less than 250 m had a peak oxygen consumption of more than 15 ml/kg/min. CONCLUSION The shuttle walk is a useful exercise test to assess potentially operable lung cancer patients with borderline lung function. However, it tends to underestimate exercise capacity at the lower range compared with peak oxygen consumption. Our data suggest that patients achieving 400 m on the shuttle walk test do not require formal measurement of oxygen consumption. In patients failing to achieve this distance we recommend assessment of peak oxygen consumption, particularly in those unable to walk 250 m, because a considerable proportion would still qualify for surgery as they had an acceptable peak oxygen consumption.
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Affiliation(s)
- T Win
- Thoracic Oncology Unit, Papworth Hospital, Cambridge, UK.
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Luckraz H, Sharples LD, Charman SC, Tsui SSL, Wallwork J, Parameshwar J, Large SR. Does Heart Transplantation Confer Survival Benefit in All Risk Groups? J Heart Lung Transplant 2005; 24:1231-4. [PMID: 16143238 DOI: 10.1016/j.healun.2004.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Revised: 08/11/2004] [Accepted: 08/15/2004] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Over 50,000 heart transplants have been performed in the last 3 decades. The global shortage of donor organs and the relaxation of candidate selection criteria over time has resulted in recent controversy about the benefits of heart transplantation for some risk groups. We assessed the survival benefit acquired in the Papworth Hospital heart transplant population overall, taking into account resuscitated marginal donors and high-risk recipients. METHODS All heart transplant patients listed between 1979 and June 2002 were analyzed (n = 1,212). Of these, 931 cardiac transplantations were done, including the use of 126 marginal donors. High-risk recipients (n = 163) were defined as patients being in the hospital, on intravenous inotropic drugs, and/or with a high transpulmonary gradient (>15 mm Hg). Using Cox regression with transplantation as a time-dependent covariate, we assessed the survival benefit of transplantation. In our model we assumed that after transplantation the initial risk of death is high relative to continued waiting, followed by an exponential decline in risk. The crossover point (COP) is the time at which the risk of death after transplantation is equal to that of continued waiting (i.e., the relative risk is 1). The equity point (EP) determines the time at which the early post-operative risk is offset by the later period of lower risk and, therefore, the time at which transplantation has a survival advantage. RESULTS Overall, the COP was at 54 days and EP at 141 days. In the marginal donor sub-group, COP was achieved at 32 days with EP at 72 days, indicating a survival benefit. The difference in the COP and EP between the borderline donor and normal donor sub-groups was not statistically significant. Post-transplant survival was not significantly different from recipients of normal cardiac allografts (p = .43). Likewise, for the high-risk recipient group, the COP and EP were at 72 and 203 days. Although post-op survival was significantly shorter than the normal-risk group, both groups achieved survival benefits. CONCLUSION Heart transplantation provides survival benefit in these risk groups of recipients in our population. This is a reflection of our active donor management protocol and rigorous donor and recipient selection process.
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Affiliation(s)
- Heyman Luckraz
- The Transplant Unit, Papworth Hospital, Cambridge, United Kingdom.
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Halstead JC, Lim E, Venkateswaran RM, Charman SC, Goddard M, Ritchie AJ. Improved survival with VATS pleurectomy-decortication in advanced malignant mesothelioma. Eur J Surg Oncol 2005; 31:314-20. [PMID: 15780570 DOI: 10.1016/j.ejso.2004.08.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2004] [Indexed: 11/24/2022] Open
Abstract
AIMS Malignant mesothelioma is increasing in incidence and no current therapy significantly prolongs survival. Previous surgical strategies involved high-risk open procedures without achieving histologically clear resection margins. We present the results of VATS debulking pleurectomy-decortication in advanced disease. METHODS A consecutive series of patients with suspected malignant mesothelioma underwent thoracoscopic assessment to determine the feasibility of decortication, where this was not possible a biopsy alone was taken. Post-operative radiotherapy was administered to port sites, but no other adjuvant therapy was given. The two groups (biopsy only and pleurectomy-decortication) were composed of patients with histologically confirmed mesothelioma [28 and 51 patients, respectively]. The primary endpoint was comparison of actuarial patient survival. Secondary endpoints included post-operative air leak and duration of hospital stay. RESULTS The overall actuarial survival was 288 days and 67% of patients had died at the time of data analysis. The groups were matched for patient and tumour-related characteristics including age (66, 64 years, p=0.39) and tumour stage (median IMIG stage 3 [IQR 2-3] both groups, p=0.54). The biopsy only group had fewer air leaks (57, 84%, p=0.01) and a shorter hospital stay (4, 8 days, p=0.03). However, the pleurectomy-decortication group had favourable actuarial survival relative to the biopsy only group (416, 127 days, p<0.001). Multivariate analysis showed early stage (p<0.001), absence of pre-operative fever (p=0.03) and pleurectomy-decortication (p<0.001) as independent predictors of survival. CONCLUSION VATS pleurectomy-decortication is feasible in the majority of cases and independently improves survival for patients with advanced malignant mesothelioma.
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Affiliation(s)
- J C Halstead
- Department of Thoracic Surgery, Papworth Hospital, Cambridge, UK.
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Luckraz H, Goddard M, Charman SC, Wallwork J, Parameshwar J, Large SR. Early mortality after cardiac transplantation: Should we do better? J Heart Lung Transplant 2005; 24:401-5. [PMID: 15797739 DOI: 10.1016/j.healun.2004.02.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2003] [Revised: 02/10/2004] [Accepted: 02/18/2004] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND According to International Society for Heart and Lung Transplantation (ISHLT) data, the 30-day survival after heart transplantation has continually improved from 84% (1979-85) to 91% (1996-2001). This has probably been achieved by better donor/recipient selection, along with improved surgical technique and immunosuppressive therapy. On the other hand, the data concerning the early causes of death after cardiac transplantation is incomplete, because in 25% of cases, an unknown cause is listed. This study investigated the incidence and causes of 30-day mortality (determined by postmortem studies) after cardiac transplantation and assessed the possibility of improvements. METHODS A retrospective study of all patients who underwent heart transplantation at Papworth Hospital from 1979 to June 2001 (n = 879) and who died within 30 days of surgery was carried out. Postmortem examination data were available for all patients. RESULTS The mean (standard deviation) recipient and donor ages were 46 (12) and 31 (12) years, respectively. Overall, the 30-day mortality was 8.5% (n = 75), 12.1% for the 1979 to 1985 period and 6.9% for the 1996 to 2001 period. The primary causes of death were graft failure (30.7%), acute rejection (22.7%) (1.3% for the 1996-2001 era), sepsis (18.7%) gastrointestinal problems (bowel infarction and pancreatitis; (9.3%), postoperative bleeding (6.7%), and other (12%). CONCLUSIONS Our 30-day mortality compares favorably with the data from the ISHLT registry, with great improvement in the early mortality. Acute rejection is no longer a major cause of early mortality. Further reduction may be achieved by a better protection of the donor heart against the effects of brainstem death and ischemic injuries. However, the quest to improve early outcome should not be at the expense of needy patients by being overselective.
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Affiliation(s)
- Heyman Luckraz
- Transplant Unit, Papworth Hospital, Cambridge, United Kingdom.
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Lim E, Cornelissen J, Routledge T, Kirtland S, Charman SC, Bellm S, Munday H, Khan O, Masood I, Large S. Clopidogrel did not inhibit platelet function early after coronary bypass surgery: A prospective randomized trial. J Thorac Cardiovasc Surg 2004; 128:432-5. [PMID: 15354104 DOI: 10.1016/j.jtcvs.2004.03.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Although the beneficial effect of aspirin prescription after coronary surgery has been established, the efficacy of clopidogrel has never been compared with that of aspirin in the critical early postoperative period. We therefore conducted a prospective, double-blind, randomized controlled trial to compare the efficacies of these antiplatelet regimens. METHODS Patients undergoing elective primary coronary artery bypass surgery were invited to participate. After the operation, patients were randomized to receive 100 mg aspirin, 325 mg aspirin, or 75 mg clopidogrel tablets daily for 5 days. Our primary outcome measure was platelet aggregation on day 5, expressed as percentage of baseline. Assessment of platelet aggregation was undertaken with the technique of Born. RESULTS From September 2002 to July 2003, a total of 54 patients were randomized into the study. There were 2 self-withdrawals and 2 protocol violations, leaving 50 patients for analysis, 34 in the aspirin group and 16 in the clopidogrel arm. Compared with baseline, the mean percentage aggregations with collagen on day 5 were 56% for aspirin and 99% for clopidogrel. The mean difference between the two arms was 42% (95% confidence interval 27%-56%) in favor of aspirin. At the same time point, the effective concentration to inhibit 50% aggregation in the samples from patients randomly assigned to receive clopidogrel were not raised for our entire panel of agonists (changes of -0.04 microg/L for collagen, -0.01 micromol/L for epinephrine, and -0.02 micromol/L for adenosine diphosphate). CONCLUSION Clopidogrel, unlike aspirin, did not inhibit platelet aggregation in the first 5 postoperative days and therefore should not be used as a sole antiplatelet agent early after coronary surgery.
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Affiliation(s)
- Eric Lim
- Departments of Cardiothoracic Surgery and Clinical Pharmacology, Papworth Hospital, Cambridge, UK.
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Barnett GC, Charman SC, Sizer B, Murray PA. Information given to patients about adverse effects of radiotherapy: a survey of patients' views. Clin Oncol (R Coll Radiol) 2004; 16:479-84. [PMID: 15490810 DOI: 10.1016/j.clon.2004.06.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
AIMS In practice, clinicians vary markedly in the amount of information they give to patients before consent for investigation or treatment is obtained. We present a study to evaluate the amount of information patients feel that they should be given. MATERIALS AND METHODS Between October 2001 and February 2002, 82 adults were enrolled into the study before commencing treatment with radiotherapy. Participants were interviewed with the aid of a questionnaire, and responses were analysed to detect differences related to age, sex, disease site, treatment intent and social class. RESULTS The distribution of responses to the interview was large. For a mild side-effect, 23 patients (28%) wanted to be informed if the risk of the side-effect was as small as 0.1%, whereas 25 patients (31%) would only want to be informed if there was either a 50% or a 100% chance of it occurring. For severe side-effects, 36 (44%) wanted to be informed of a 0.1% risk, whereas 13 (16%) only wanted to be informed if the risk was either 50% or 100%. There was no association with sex, treatment intent (radical or palliative), social class or disease site. Information requirements tended to be greater in people under 60 years. This reached statistical significance (P = 0.007) for severe side-effects, where younger patients were more likely to want to be informed of a side-effect if there was a 10% or less chance of it occurring. CONCLUSIONS Information needs varied widely within our survey population. It is difficult to predict how much information patients feel they need before giving informed consent. Therefore, a patient-centred approach must involve tailoring information to individual patient requirements.
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Affiliation(s)
- G C Barnett
- Oncology Centre, Addenbrooke's Hospital, Cambridge, UK.
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Luckraz H, Goddard M, McNeil K, Atkinson C, Charman SC, Stewart S, Wallwork J. Microvascular changes in small airways predispose to obliterative bronchiolitis after lung transplantation. J Heart Lung Transplant 2004; 23:527-31. [PMID: 15135366 DOI: 10.1016/j.healun.2003.07.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2003] [Accepted: 07/01/2003] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is strong evidence that obliterative bronchiolitis (OB) in lung transplant recipients is related to acute rejection as graded by parenchymal perivascular infiltrates. OB (chronic rejection) is a small airways, rather than a parenchymal, scarring process. Moreover, there has been no study of the microcirculation in the small airways in lung transplantation. This study assesses the microvasculature around small airways (SA) in post-mortem lung allograft specimens. METHODS The microvasculature of SA (n = 19) from 5 patients who died within 24 hours of lung transplantation (Group A) and SA in OB lungs (11 patients, median post-transplant survival 1,371 days) was assessed by the use of monoclonal antibodies to the vascular endothelium, namely von Willebrand factor (vWF) and CD31. The second group was further sub-divided into Group B (airways not obliterated, n = 18), Group C (sub-total airways obliteration, n = 21) and Group D (airways with total luminal obstruction, n = 14). RESULTS The measured median circumference of the SA in the 4 groups was 2.1, 2.1, 2.5 and 2.3 mm, respectively (p = 0.66). Using CD31 as the endothelial marker, the median number of blood vessels per unit length of airway circumference (BVPL) was 3.5 vessels/mm for Group A, 0.8 for Group B, 1.3 for Group C and 2.8 for Group D, (p < 0.001). Large blood vessels (circumference >0.20 mm) were present in 95%, 11%, 14% and 21% of each group, respectively (p < 0.001). Similar trends were confirmed with the vWF endothelial antibodies. CONCLUSIONS OB after lung transplantation is associated with a decrease in microvascular supply to the small airway. This ischemic event may lead to airway damage or increase the tendency to repair by scarring. The small airways then appear to respond to this insult by angiogenesis, which may either occur too late to prevent permanent airway damage or be inadequate in restoring adequate blood supply to the airway.
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Trull AK, Akhlaghi F, Charman SC, Endenberg S, Majid O, Cornelissen J, Steel L, Parameshwar J, Wallwork J, Large S. Immunosuppression, eotaxin and the diagnostic changes in eosinophils that precede early acute heart allograft rejection. Transpl Immunol 2004; 12:159-66. [PMID: 14967314 DOI: 10.1016/s0966-3274(03)00077-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2003] [Revised: 07/28/2003] [Accepted: 08/05/2003] [Indexed: 10/27/2022]
Abstract
Peripheral blood eosinophil counts (EOS) are undetectable in 40% blood samples sent for routine haematology at Papworth Hospital during the first 3 months after heart transplantation (HTx). Increases in EOS usually precede the development of allograft rejection by a median of 4 days. We compared the effects of cyclosporin (dose and total blood concentration), prednisolone (dose and both total and unbound plasma concentrations) and azathioprine, as well as plasma concentrations of the CCR-3 chemokines, eotaxin and RANTES, on changes in EOS in 47 consecutive HTx recipients, with a median follow-up of 90 (IQR 85-95) days. Multivariate analysis confirmed the independent association between both prednisolone dose (P<0.0001) and eotaxin (P<0.0001) and changes in EOS. The plasma eotaxin concentration was, in turn, most closely associated with the cyclosporin dose (P<0.001) and plasma prednisolone concentration (P=0.022). The blood cyclosporin concentration (P=0.028), EOS (P=0.012) and prednisolone dose (P=0.015) were all independently associated with the risk of treated acute rejection. When prednisolone pharmacokinetic parameters were substituted for the prednisolone dose in this multivariate model, only the pharmacokinetic parameter retained a significant association with the risk of rejection. Changes in EOS preceding cardiac allograft rejection are directly associated with plasma eotaxin concentrations and indirectly with prednisolone dosage. Cyclosporin may also indirectly influence these changes by inhibiting eotaxin production. EOS, prednisolone dose and blood cyclosporin concentrations were independently associated with the risk of acute rejection. The total and unbound fractions of prednisolone in plasma appear to be even more closely related to rejection but are difficult to measure. Monitoring EOS, as a surrogate measure of prednisolone immunosuppression, may be more cost-effective for controlling rejection than conventional cyclosporin monitoring in the first 6 weeks after HTx.
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Affiliation(s)
- Andrew K Trull
- Department of Clinical Pharmacology, Papworth Hospital, Cambridge CB3 8RE, UK.
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Groves AM, Win T, Charman SC, Wisbey C, Pepke-Zaba J, Coulden RA. Semi-quantitative assessment of tricuspid regurgitation on contrast-enhanced multidetector CT. Clin Radiol 2004; 59:715-9. [PMID: 15262546 DOI: 10.1016/j.crad.2004.02.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [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: 10/26/2022]
Abstract
AIM To assess whether the early regurgitation of intravenous contrast medium into the inferior vena cava (IVC) and/or hepatic veins on computed tomography (CT), indicates tricuspid regurgitation (TR), and if so, whether it be used to grade severity. MATERIALS AND METHODS We identified 86 consecutive patients that had been investigated for possible pulmonary endarterectomy at Papworth Hospital. From these, 61 patients were selected in whom CT, transthoracic echocardiography, and right heart catheterization (RHC) had been performed within 6 weeks. Using an arbitrary visual scale, the degree of TR assessed by intravenous contrast-enhanced CT was compared with echocardiography. Results were analysed using a kappa weighted statistical test. In addition, CT and echocardiographic assessments of TR severity were correlated with pulmonary artery pressure measurements obtained by RHC (Spearman's rank correlation coefficient). RESULTS CT assessment of TR had a sensitivity of 90.4% and a specificity of 100% in detecting echocardiographic TR. For TR graded as more than trivial by echocardiography, sensitivity of CT was 100%. With respect to RHC data, the correlation between severity assessment of TR between CT and echocardiography using the Kappa weighted coefficient was 0.56 (moderately good agreement). With respect to RHC data, the correlation between mean pulmonary pressure and TR grading on CT and echocardiography was r = 0.685 (p < 0.001) and r = 0.727 (p < 0.001), respectively. CONCLUSION Early opacification of the IVC or hepatic veins on first-pass contrast-enhanced CT almost invariably indicates TR. There is moderately good agreement between CT and echocardiographic assessment of the severity of TR. Both CT and echocardiographic grading of TR correlate well with RHC measurements of pulmonary artery pressure.
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Affiliation(s)
- A M Groves
- Papworth Hospital, Papworth Everard, Cambridge, UK.
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Luckraz H, Parameshwar J, Charman SC, Firth J, Wallwork J, Large S. Short- and long-term outcomes of combined cardiac and renal transplantation with allografts from a single donor. J Heart Lung Transplant 2004; 22:1318-22. [PMID: 14672746 DOI: 10.1016/s1053-2498(03)00030-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [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: 11/15/2022] Open
Abstract
Coexisting end-stage heart and kidney failure can be treated by combined cardiac and renal transplantation. This study reviews the short- and long-term outcomes after such a procedure over a 16-year period at a single institution. All patients who underwent single-donor simultaneous heart and kidney transplantation during the period of March 1986 to April 2002 (including heart retransplantation) were included (n = 13). They were listed for combined heart and kidney transplantation as they fulfilled our criteria for irreversible end-stage organ failure. Retrospective review of patient data from the transplant database, patient case notes and post-mortem reports were carried out. The mean (SD) recipient age was 45 (12) years and there were 2 females. The mean pre-operative creatinine level was 724 (415) micromol/liter with 9 patients (69.2%) on continuous ambulatory peritoneal dialysis and 2 patients (15.4%) on hemodialysis prior to transplantation. The 30-day mortality rate was 15.4% (2 of 13). For surviving patients the mean creatinine level at hospital discharge was 158 (93) micromol/liter. The mean number of acute cardiac rejection episodes per 100 patient-days was significantly lower (p = 0.01) than that for the heart-only transplant group (n = 760) during the same period. The median (interquartile range) post-operative survival was 1,969 (620 to 3,468) days. The actuarial survival rates (95% confidence interval) at 1 and 10 years were 77% (54% to 100%) and 67% (40% to 94%), respectively, and were not significantly different from the isolated heart transplant population (p = 0.68). Only 1 episode of acute renal rejection was diagnosed on clinical grounds, which was treated accordingly. There was no renal allograft loss in the long-term survivors. Combined cardiac and renal transplantation with allografts from the same donor has acceptable short- and long-term outcomes for patients with coexisting end-stage cardiac and renal failure. This group of patients may also experience fewer acute rejection episodes post-operatively.
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Affiliation(s)
- Heyman Luckraz
- Transplant Unit, Papworth Hospital, Cambridge CB3 8RE, UK.
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Luckraz H, Charman SC, Parameshwar J, Tsui SS, Dunning J, Wallwork J, Large SR. Are non–brain stem-dead cardiac donors acceptable donors? J Heart Lung Transplant 2004; 23:330-3. [PMID: 15019643 DOI: 10.1016/s1053-2498(02)01186-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2002] [Revised: 11/07/2002] [Accepted: 11/08/2002] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The deleterious effects of brainstem death (BSD) on donor cardiac function and endothelial integrity have been documented previously. Domino cardiac donation (heart of a heart-lung recipient transplanted into another recipient) is a way to avoid the effects of brainstem death and may confer both short- and long-term benefits to allograft recipients. METHODS This study evaluates short- and long-term outcome in heart recipients of BSD donors (cadaveric) as compared with domino hearts explanted from patients who underwent heart-lung transplantation. RESULTS Patients having undergone cardiac transplantation between April 1989 and August 2001 at Papworth Hospital were included (n = 571). Domino donor hearts were used in 81 (14%) of these cases. The pre-operative transpulmonary gradient was not significantly different between the two groups (p = 0.7). There was no significant difference in 30-day mortality (4.9% for domino vs 8.6% for BSD, p = 0.38) or in actuarial survival (p = 0.72). Ischemic time was significantly longer in the BSD group (p < 0.001). Acute rejection and infection episodes were not significantly different (p = 0.24 vs: 0.08). Relative to the BSD group, the risk (95% confidence interval) of acute rejection in the domino group was 0.89 (0.73 to 1.08). Similarly, the relative risk of infection was 0.78 (0.59 to 1.03). The 5-year actuarial survival rates (95% confidence interval) were 78% (69% to 87%) and 69% (65% to 73%) in the domino and BSD groups respectively. Angiography data at 2 years were available in 50 (62%) and 254 (52%) patients in the domino and BSD groups, respectively. The rates for 2-year freedom from cardiac allograft vasculopathy (CAV) were 96% (91% to 100%) and 93% (90% to 96%), respectively. CONCLUSION Despite the lack of endothelial cell activation after brainstem death and a shorter ischemic time, the performance of domino donor hearts was similar to that of BSD donor hearts. This may indicate a similar pathology (i.e., endothelial cell activation) in the domino donors.
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Affiliation(s)
- Heyman Luckraz
- Transplant Unit, Papworth Hospital, Papworth Everard, Cambridge, UK
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