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Kardos P, Correia de Sousa J, Heininger U, Konstantopoulos A, MacIntyre CR, Middleton D, Nolan T, Papi A, Rendon A, Rizzo A, Sampson K, Sette A, Sobczyk E, Tan T, Weil-Olivier C, Weinberger B, Wilkinson T, Wirsing von König CH. Understanding the impact of adult pertussis and current approaches to vaccination: A narrative review and expert panel recommendations. Hum Vaccin Immunother 2024; 20:2324547. [PMID: 38564339 PMCID: PMC10989709 DOI: 10.1080/21645515.2024.2324547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/25/2024] [Indexed: 04/04/2024] Open
Abstract
Pertussis has several notable consequences, causing economic burden, increased strain on healthcare facilities, and reductions in quality of life. Recent years have seen a trend toward an increase in pertussis cases affecting older children and adults. To boost immunity, and protect vulnerable populations, an enduring approach to vaccination has been proposed, but gaps remain in the evidence surrounding adult vaccination that are needed to inform such a policy. Gaps include: the true incidence of pertussis and its complications in adults; regional variations in disease recognition and reporting; and incidence of severe disease, hospitalizations, and deaths in older adults. Better data on the efficacy/effectiveness of pertussis vaccination in adults, duration of protection, and factors leading to poor vaccine uptake are needed. Addressing the critical evidence gaps will help highlight important areas of unmet need and justify the importance of adult pertussis vaccination to healthcare professionals, policymakers, and payers.
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Affiliation(s)
- Peter Kardos
- Group Practice & Center, Allergy, Respiratory and Sleep Medicine, Maingau Hospital of the Red Cross, Frankfurt am Main, Germany
| | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute, School of Medicine, University of Minho School of Medicine, Braga, Portugal
| | - Ulrich Heininger
- Pediatric Infectious Diseases and Vaccinology, University of Basel Children’s Hospital, BaselSwitzerland
| | | | - C. Raina MacIntyre
- Kirby Institute, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Donald Middleton
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Terry Nolan
- Department of Infectious Diseases, University of Melbourne, Melbourne, Australia
| | - Alberto Papi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Adrian Rendon
- Pulmonary/Critical Care Division, Autonomous University of Nuevo León, San Nicolás de los Garza, Mexico
| | | | - Kim Sampson
- Immunisation Coalition, Melbourne, Australia
| | - Alessandro Sette
- Center for Infectious Disease and Vaccine Research, La Jolla Institute for Immunology, San Diego, USA
| | - Elizabeth Sobczyk
- AMDA – The Society for Post-Acute and Long-Term Care Medicine, Denver, USA
| | - Tina Tan
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | | | - Birgit Weinberger
- Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Austria
| | - Tom Wilkinson
- Faculty of Medicine, University of Southampton, Southampton, UK
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Ritchie AI, Donaldson GC, Hoffman EA, Allinson JP, Bloom CI, Bolton CE, Choudhury G, Gerard SE, Guo J, Alves-Moreira L, McGarvey L, Sapey E, Stockley RA, Yip KP, Singh D, Wilkinson T, Fageras M, Ostridge K, Jöns O, Bucchioni E, Compton CH, Jones P, Mezzi K, Vestbo J, Calverley PMA, Wedzicha JA. Structural Predictors of Lung Function Decline in Young Smokers with Normal Spirometry. Am J Respir Crit Care Med 2024; 209:1208-1218. [PMID: 38175920 DOI: 10.1164/rccm.202307-1203oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/04/2024] [Indexed: 01/06/2024] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) due to tobacco smoking commonly presents when extensive lung damage has occurred. Objectives: We hypothesized that structural change would be detected early in the natural history of COPD and would relate to loss of lung function with time. Methods: We recruited 431 current smokers (median age, 39 yr; 16 pack-years smoked) and recorded symptoms using the COPD Assessment Test (CAT), spirometry, and quantitative thoracic computed tomography (QCT) scans at study entry. These scan results were compared with those from 67 never-smoking control subjects. Three hundred sixty-eight participants were followed every six months with measurement of postbronchodilator spirometry for a median of 32 months. The rate of FEV1 decline, adjusted for current smoking status, age, and sex, was related to the initial QCT appearances and symptoms, measured using the CAT. Measurements and Main Results: There were no material differences in demography or subjective CT appearances between the young smokers and control subjects, but 55.7% of the former had CAT scores greater than 10, and 24.2% reported chronic bronchitis. QCT assessments of disease probability-defined functional small airway disease, ground-glass opacification, bronchovascular prominence, and ratio of small blood vessel volume to total pulmonary vessel volume were increased compared with control subjects and were all associated with a faster FEV1 decline, as was a higher CAT score. Conclusions: Radiological abnormalities on CT are already established in young smokers with normal lung function and are associated with FEV1 loss independently of the impact of symptoms. Structural abnormalities are present early in the natural history of COPD and are markers of disease progression. Clinical trial registered with www.clinicaltrials.gov (NCT03480347).
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Affiliation(s)
- Andrew I Ritchie
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- AstraZeneca, Cambridge, United Kingdom
| | - Gavin C Donaldson
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Eric A Hoffman
- Department of Radiology and
- Roy J. Carver Department of Biomedical Engineering, Medicine and Biomedical Engineering, University of Iowa, Iowa City, Iowa
| | - James P Allinson
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Royal Brompton Hospital, London, United Kingdom
| | - Chloe I Bloom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Charlotte E Bolton
- NIHR Nottingham Biomedical Research Centre
- Centre for Respiratory Research, NIHR Nottingham, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Gourab Choudhury
- ELEGI and COLT Laboratories, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Sarah E Gerard
- Roy J. Carver Department of Biomedical Engineering, Medicine and Biomedical Engineering, University of Iowa, Iowa City, Iowa
| | | | - Luana Alves-Moreira
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Lorcan McGarvey
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
- Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Robert A Stockley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - K P Yip
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Dave Singh
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Tom Wilkinson
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, United Kingdom
| | | | - Kristoffer Ostridge
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- AstraZeneca, Gothenburg, Sweden
| | - Olaf Jöns
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | | | - Paul Jones
- GlaxoSmithKline, Brentford, United Kingdom
| | | | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Peter M A Calverley
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Jadwiga A Wedzicha
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Solanki G, Wilkinson T, Myburgh NG, Cornell JE, Brijlal V. South African healthcare reforms towards universal healthcare - where to next? S Afr Med J 2024; 114:e1571. [PMID: 38525573 DOI: 10.7196/samj.2024.v114i3.1571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Indexed: 03/26/2024] Open
Abstract
The National Assembly approval of the National Health Insurance (NHI) Bill represents an important milestone, but there are many uncertainties concerning its implementation and timeline. The challenges faced by the South African healthcare system are huge, and we cannot afford to wait for NHI to address them all. It is critical that the process of strengthening the health system to advance universal healthcare (UHC) begins now, and there are several viable initiatives that can be implemented without delay. This article examines potential scenarios after the Bill is passed and ways in which UHC could be advanced. It begins with an overview of the trajectory of health system reform since 1994, then examines the scenarios that may emerge once the Bill is passed by Parliament and makes a case for finding ways in which UHC could be advanced within the country, regardless of any legal or financial barriers that may delay or limit NHI implementation.
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Affiliation(s)
- G Solanki
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa; Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa; NMG Consultants and Actuaries, Cape Town, South Africa.
| | - T Wilkinson
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - N G Myburgh
- Faculty of Dentistry and World Heath Organization Collaborating Centre for Oral Health, University of the Western Cape, Cape Town, South Africa.
| | - J E Cornell
- Nelson Mandela School of Public Governance, University of Cape Town, South Africa.
| | - V Brijlal
- Clinton Health Access Initiative, Pretoria, South Africa.
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Wilkinson T, Tomic D, Boyle E, Burren D, Elghattis Y, Jenkins A, Keesing C, Middleton S, Nanayakkara N, Williman J, de Bock M, Cohen ND. Study protocol for a randomised open-label clinical trial examining the safety and efficacy of the Android Artificial Pancreas System (AAPS) with advanced bolus-free features in adults with type 1 diabetes: the 'CLOSE IT' (Closed Loop Open SourcE In Type 1 diabetes) trial. BMJ Open 2024; 14:e078171. [PMID: 38382954 PMCID: PMC10882371 DOI: 10.1136/bmjopen-2023-078171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
INTRODUCTION Multiple automated insulin delivery (AID) systems have become commercially available following randomised controlled trials demonstrating benefits in people with type 1 diabetes (T1D). However, their real-world utility may be undermined by user-associated burdens, including the need to carbohydrate count and deliver manual insulin boluses. There is an important need for a 'fully automated closed loop' (FCL) AID system, without manual mealtime boluses. The (Closed Loop Open SourcE In Type 1 diabetes) trial is a randomised trial comparing an FCL AID system to the same system used as a hybrid closed loop (HCL) in people with T1D, in an outpatient setting over an extended time frame. METHODS AND ANALYSIS Randomised, open-label, parallel, non-inferiority trial comparing the Android Artificial Pancreas System (AAPS) AID algorithm used as FCL to the same algorithm used as HCL. Seventy-five participants aged 18-70 will be randomised (1:1) to one of two treatment arms for 12 weeks: (a) FCL-participants will be advised not to bolus for meals and (b) HCL-participants will use the AAPS AID algorithm as HCL with announced meals. The primary outcome is the percentage of time in target sensor glucose range (3.9-10.0 mmol/L). Secondary outcomes include other glycaemic metrics, safety, psychosocial factors, platform performance and user dietary factors. Twenty FCL arm participants will participate in a 4-week extension phase comparing glycaemic and dietary outcomes using NovoRapid (insulin aspart) to Fiasp (insulin aspart and niacinamide). ETHICS AND DISSEMINATION Approvals are by the Alfred Health Ethics Committee (615/22) (Australia) and Health and Disability Ethics Committees (2022 FULL 13832) (New Zealand). Each participant will provide written informed consent. Data protection and confidentiality will be ensured. Study results will be disseminated by publications, conferences and patient advocacy groups. TRIAL REGISTRATION NUMBERS ACTRN12622001400752 and ACTRN12622001401741.
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Affiliation(s)
- Tom Wilkinson
- University of Otago Christchurch, Christchurch, New Zealand
| | - Dunya Tomic
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Erin Boyle
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - David Burren
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Yasser Elghattis
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Alicia Jenkins
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Sonia Middleton
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | | | - Martin de Bock
- University of Otago Christchurch, Christchurch, New Zealand
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
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Wilkinson T, Li B, Soule S, Hunt P. The utility of rested prolactin sampling in the evaluation of hyperprolactinaemia. Intern Med J 2024; 54:307-311. [PMID: 37605836 DOI: 10.1111/imj.16208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 07/27/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND AND AIMS Serum prolactin levels may be elevated by venepuncture stress. We investigated the utility of a rested prolactin sample, obtained through an indwelling venous cannula, in preventing the overdiagnosis of hyperprolactinaemia. METHODS Patients at our institution undergo serial prolactin sampling, usually over 40 min, when investigating hyperprolactinaemia. We retrospectively reviewed all serial prolactin sampling performed during a 3-year period. Patients with possible medication-induced hyperprolactinaemia and macroprolactin interference were excluded. We assessed the effect of venepuncture-associated stress on hyperprolactinaemia with the main outcome being normalisation of serum prolactin at the end of serial sampling. RESULTS Ninety-three patients with documented hyperprolactinaemia (range 360-1690 mU/L) were included in the analysis. Prolactin decreased during serial sampling in 73 patients (78%), suggesting a prevalent effect of venepuncture stress. The final prolactin sample was normal in 50 patients (54%), consistent with stress hyperprolactinaemia rather than pathological hyperprolactinaemia. Patients with a referral prolactin result greater than two times the upper reference limit (URL) were less likely (15%) to have a normal prolactin result on serial sampling. Measurement of a single rested prolactin sample from an indwelling cannula showed the same diagnostic utility as serial sampling. CONCLUSION Serum prolactin results are frequently elevated by the stress of venepuncture. Confirmation of pathological hyperprolactinaemia in a rested sample obtained from an indwelling venous cannula is recommended in patients with mild hyperprolactinaemia, particularly when the referral prolactin is less than two times the URL.
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Affiliation(s)
- Tom Wilkinson
- Department of Endocrinology, Christchurch Hospital, Te Whatu Ora Health New Zealand, Christchurch, New Zealand
| | - Bobby Li
- Canterbury Health Laboratories, Christchurch, New Zealand
| | - Steven Soule
- Department of Endocrinology, Christchurch Hospital, Te Whatu Ora Health New Zealand, Christchurch, New Zealand
- Department of Medicine, University of Otago (Christchurch), Christchurch, New Zealand
| | - Penny Hunt
- Department of Endocrinology, Christchurch Hospital, Te Whatu Ora Health New Zealand, Christchurch, New Zealand
- Department of Medicine, University of Otago (Christchurch), Christchurch, New Zealand
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Adams EJ, van Doornewaard A, Ma Y, Ahmed N, Cheng MK, Watz H, Ichinose M, Wilkinson T, Bhutani M, Licskai CJ, Turner KME. Estimating the Health and Economic Impact of Improved Management in Prevalent Chronic Obstructive Pulmonary Disease Populations in England, Germany, Canada, and Japan: A Modelling Study. Int J Chron Obstruct Pulmon Dis 2023; 18:2127-2146. [PMID: 37789931 PMCID: PMC10543939 DOI: 10.2147/copd.s416988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/17/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction COPD is a leading cause of morbidity and mortality globally. Management is complex and costly. Although international quality standards for diagnosis and management exist, opportunities remain to improve outcomes, especially in reducing avoidable hospitalisations. Objective To estimate the potential health and economic impact of improved adherence to guideline-recommended care for prevalent, on-treatment COPD populations in four high-income settings. Methods A disease simulation model was developed to evaluate the impact of theoretical improvements to COPD management, comparing outcomes for usual care and policy scenarios for interventions that reduce avoidable hospitalisations: 1) increased attendance (50% vs 31-38%) of early follow-up review after severe exacerbation hospitalisation; 2) increased access (30% vs 5-10%) to an integrated disease management (IDM) programme that provides guideline adherent care. Results For cohorts of 100,000 patients, Policy 1 yielded additional life years (England: 523; Germany: 759; Canada: 1316; Japan: 512) and lifetime cost savings (-£2.89 million; -€6.58 million; -$40.08 million; -¥735.58 million). For Policy 2, additional life years (2299; 3619; 3656) and higher lifetime total costs (£38.15 million; €35.58 million; ¥1091.53 million) were estimated in England, Germany and Japan, and additional life years (4299) and cost savings (-$20.52 million) in Canada. Scenarios found that the cost impact depended on the modelled intervention effect size. Conclusion Interventions that reduce avoidable hospitalisations are estimated to improve survival and may generate cost savings. This study provides evidence on the theoretical impact of policies to improve COPD care and highlights priority areas for further research to support evidence-based policy decisions.
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Affiliation(s)
| | | | - Yixuan Ma
- Aquarius Population Health, London, UK
| | | | | | - Henrik Watz
- Pulmonary Research Institute at Lungen Clinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | | | - Tom Wilkinson
- Southampton University Faculty of Medicine, Southampton, UK
| | | | - Christopher J Licskai
- London Health Sciences Centre, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- Asthma Research Group Windsor Essex County Inc., Windsor, Ontario, Canada
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7
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Willcox ML, Hu XY, Oliver T, Thorne K, Boxall C, He G, Simpson C, Brotherwood B, O’Neil A, Waugh R, Tilt E, Trill J, Goward N, Francis N, Thomas M, Little P, Wilkinson T, Liu JP, Griffiths G, Moore M. Treating acute exacerbations of COPD with Chinese herbal medicine to aid antibiotic use reduction (Excalibur): a randomised double-blind, placebo-controlled feasibility trial. Front Pharmacol 2023; 14:1221905. [PMID: 37818189 PMCID: PMC10561384 DOI: 10.3389/fphar.2023.1221905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 09/08/2023] [Indexed: 10/12/2023] Open
Abstract
Background: Although many acute exacerbations of COPD (AECOPD) are triggered by non-bacterial causes, they are often treated with antibiotics. Preliminary research suggests that the Chinese herbal medicine "Shufeng Jiedu" (SFJD), may improve recovery and therefore reduce antibiotic use in patients with AECOPD. Aims: To assess the feasibility of conducting a randomised placebo-controlled clinical trial of SFJD for AECOPD in UK primary care. Methods: GPs opportunistically recruited patients experiencing an AECOPD. Participants were randomised 1:1 to usual care plus SFJD or placebo for 14 days. Participants, GPs and research nurses were blinded to treatment allocation. GPs could prescribe immediate, delayed or no antibiotics, with delayed prescribing encouraged where appropriate. Participants were asked to complete a participant diary, including EXACT-PRO and CAT™ questionnaires for up to 4 weeks. Outcomes included recruitment rate and other measures of study feasibility described using only descriptive statistics and with no formal comparisons between groups. We also conducted qualitative interviews with recruited and non-recruited COPD patients and clinicians, analysed using framework analysis. Results: Over 6 months, 19 participants (6 SFJD, 13 placebo) were recruited. Sixteen (84%) participants returned diaries or provided a diary by recall. Overall, 1.3 participants were recruited per 1,000 patients on the COPD register per month open. Median duration of treatment was 9.8 days in the intervention group vs 13.3 days in the placebo group. The main reason for discontinuation in both groups was perceived side-effects. in both groups. Point estimates for both the EXACT-PRO and CAT™ outcomes suggested possible small benefits of SFJD. Most patients and clinicians were happy to try SFJD as an alternative to antibiotics for AECOPD. Recruitment was lower than expected because of the short recruitment period, the lower incidence of AECOPD during the COVID-19 pandemic, patients starting antibiotics from "rescue packs" before seeing their GP, and workforce challenges in primary care. Conclusion: Recruitment was impaired by the COVID-19 pandemic. Nevertheless, we were able to demonstrate the feasibility of recruiting and randomising participants and identified approaches to address recruitment challenges such as including the trial medication in COPD patients' "rescue packs" and delegating recruitment to a central trials team. Clinical Trial Registration: Identifier, ISRCTN26614726.
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Affiliation(s)
- Merlin L. Willcox
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Xiao-Yang Hu
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Tom Oliver
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Kerensa Thorne
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Cherish Boxall
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - George He
- Phoenix Medical Ltd, Chelmsford, United Kingdom
| | - Catherine Simpson
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Becci Brotherwood
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Alice O’Neil
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Robert Waugh
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Emma Tilt
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Jeanne Trill
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Neville Goward
- Patient and Public Representative, Southampton, United Kingdom
| | - Nick Francis
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Michael Thomas
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Paul Little
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Tom Wilkinson
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Jian-Ping Liu
- Centre for Evidence-based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Michael Moore
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
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8
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Wilkinson T, De Soyza A, Carroll M, Chalmers JD, Crooks MG, Griffiths G, Shankar-Hari M, Ho LP, Horsley A, Kell C, Lara B, Mishra B, Moate R, Page C, Pandya H, Raw J, Reid F, Saralaya D, Scott IC, Siddiqui S, Ustianowski A, van Zuydam N, Woodcock A, Singh D. A randomised phase 2a study to investigate the effects of blocking interleukin-33 with tozorakimab in patients hospitalised with COVID-19: ACCORD-2. ERJ Open Res 2023; 9:00249-2023. [PMID: 37868151 PMCID: PMC10588785 DOI: 10.1183/23120541.00249-2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/25/2023] [Indexed: 10/24/2023] Open
Abstract
Background Increased serum interleukin (IL)-33 predicts poor outcomes in patients hospitalised with coronavirus disease 2019 (COVID-19). We examined the efficacy and safety of tozorakimab, a monoclonal antibody that neutralises IL-33, in improving outcomes in ACCORD-2 (EudraCT: 2020-001736-95). Methods ACCORD-2 was an open-label, phase 2a study in adults hospitalised with COVID-19. Patients were randomised 1:1 to tozorakimab 300 mg plus standard of care (SoC) or SoC alone. The primary end-point was time to clinical response (sustained clinical improvement of ≥2 points on the World Health Organization ordinal scale, discharge from hospital or fit for discharge) by day 29. Other end-points included death or respiratory failure, mortality and intensive care unit admission by day 29, and safety. Serum IL-33/soluble stimulated-2 (sST2) complex levels were measured by high-sensitivity immunoassay. Results Efficacy analyses included 97 patients (tozorakimab+SoC, n=53; SoC, n=44). Median time to clinical response did not differ between the tozorakimab and SoC arms (8.0 and 9.5 days, respectively; HR 0.96, 80% CI 0.70-1.31; one-sided p=0.33). Tozorakimab was well tolerated and the OR for risk of death or respiratory failure with treatment versus SoC was 0.55 (80% CI 0.27-1.12; p=0.26), while the OR was 0.31 (80% CI 0.09-1.06) in patents with high baseline serum IL-33/sST2 complex levels. Conclusions Overall, ACCORD-2 results suggest that tozorakimab could be a novel therapy for patients hospitalised with COVID-19, warranting further investigation in confirmatory phase 3 studies.
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Affiliation(s)
- Tom Wilkinson
- NIHR Southampton Biomedical Research Centre and University of Southampton, Southampton, UK
| | - Anthony De Soyza
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Miles Carroll
- Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - James D. Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | | | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Ling-Pei Ho
- Medical Research Council Human Immunology Unit, University of Oxford, Oxford, UK
| | - Alex Horsley
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Chris Kell
- Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Beatriz Lara
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, London, UK
| | - Hitesh Pandya
- Clinical Development, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | | | - Fred Reid
- Clinical Development, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Dinesh Saralaya
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ian C. Scott
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Salman Siddiqui
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Andy Ustianowski
- Regional Infection Unit, North Manchester General Hospital, Manchester, UK
| | | | - Ashley Woodcock
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Dave Singh
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, UK
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9
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Wilkinson T, Beaver S, Macartney M, McArthur E, Yadav V, Lied‐Lied A. Burden of respiratory syncytial virus in adults in the United Kingdom: A systematic literature review and gap analysis. Influenza Other Respir Viruses 2023; 17:e13188. [PMID: 37744994 PMCID: PMC10511839 DOI: 10.1111/irv.13188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/31/2023] [Accepted: 08/09/2023] [Indexed: 09/26/2023] Open
Abstract
Despite the growing recognition of a potentially significant respiratory syncytial virus (RSV) disease burden in adults, relevant evidence in the United Kingdom (UK) is limited. This systematic literature review (SLR) aimed to identify the disease burden of RSV in UK adults, including certain high-risk subgroups and existing evidence gaps. Published studies (2011 onwards) reporting epidemiological, economic and clinical burden outcomes in UK adults (≥15 years) with RSV were identified from indexed databases, including MEDLINE, Embase and the Cochrane library. High-risk groups included elderly (≥65 years), immunocompromised, co-morbid and co-infected patients. Outcomes included RSV incidence/prevalence, mortality, clinical presentation and direct/indirect resource use/costs. Twenty-eight publications on 28 unique studies were identified, mostly in general/respiratory indicator (n = 17), elderly (n = 10) and immunocompromised (n = 6) cohorts. Main outcomes reported in the general/respiratory indicator cohort were RSV infection incidence (seasonal/annual: 0.09-17.9%/6.6-15.1%), mortality (8,482 deaths/season) and direct resource use (including mean general practitioner [GP] episodes/season: 487,247). Seasonal/annual incidence was 14.6-26.5%/0.7-16% in high-risk cohorts. Attributed to RSV in the elderly were 7,915 deaths/season and 175,070 mean GP episodes/season. Only two studies reported on co-morbid cohorts. Clinical burden outcomes were only reported in general and immunocompromised patients, and no evidence was found in any cohort on indirect economic burden or RSV complications. Evidence captured suggests that RSV may have a substantial burden in UK adults. However, available data were limited and highly heterogenous, with further studies needed to characterise the burden of RSV in adults and to validate our findings.
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Affiliation(s)
- Tom Wilkinson
- Clinical and Experimental SciencesUniversity of Southampton Faculty of MedicineSouthamptonUK
- National Institute for Health and Care Research Southampton Biomedical Research CentreSouthamptonUK
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10
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Wilkinson T, Cawood T, Lim A, Roche D, Jiang J, Thomson B, Marais M, Hunt P. Correlation of ACR TI-RADS and Patient Outcomes in a Real-World Cohort Presenting for Thyroid Ultrasonography. J Endocr Soc 2023; 7:bvad119. [PMID: 37795193 PMCID: PMC10546907 DOI: 10.1210/jendso/bvad119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Indexed: 10/06/2023] Open
Abstract
Context The American College of Radiology Thyroid Image Reporting and Data System (ACR TI-RADS) was developed to predict malignancy risk in thyroid nodules using ultrasound features. TI-RADS was derived from a database of patients already selected for fine-needle aspiration (FNA), raising uncertainty about applicability to unselected patients. Objective We aimed to assess the effect of ACR TI-RADS reporting in unselected patients presenting for thyroid ultrasound in a real-world setting. Methods Records for all patients presenting for thyroid ultrasonography in Canterbury, New Zealand, were reviewed across two 18-month periods, prior to and after implementation of TI-RADS reporting. Patient outcomes were compared between the 2 periods. Malignancy rates were calculated for nodules 10 mm or larger with a definitive FNA or histology result. Results A total of 1210 nodules were identified in 582 patients prior to implementation of TI-RADS; 1253 nodules were identified in 625 patients after implementation of TI-RADS. TI-RADS category was associated with malignancy rate (0% in TR1 and TR2, 3% in TR3, 5% in TR4, 12% in TR5; P = .02); however, 63% of nodules were graded TR3 or TR4, for which malignancy rate did not meaningfully differ from baseline risk. After implementation of TI-RADS there was a small reduction in the proportion of patients proceeding to FNA (49% vs 60%; P < .01) or surgery (14% vs 18%; P < .05), with no difference in cancer diagnoses (3% vs 4%, not significant). Conclusion TI-RADS category is associated with malignancy rate and may alter clinical decision-making in a minority of patients; however, it is nondiscriminatory in the majority of nodules. In this study of unselected patients, nodules classified as TR5 and thus considered "highly suspicious" for cancer had only a modest risk of malignancy.
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Affiliation(s)
- Tom Wilkinson
- Department of Endocrinology, Te Whatu Ora/Health New Zealand Waitaha/Canterbury, Christchurch 8011, New Zealand
| | - Tom Cawood
- Department of Endocrinology, Te Whatu Ora/Health New Zealand Waitaha/Canterbury, Christchurch 8011, New Zealand
| | - Anthony Lim
- Department of Radiology, Te Whatu Ora/Health New Zealand Waitaha/Canterbury, Christchurch 8011, New Zealand
| | - David Roche
- Canterbury Southern Community Laboratories, Christchurch 8051, New Zealand
| | - Jasmine Jiang
- Department of Endocrinology, Te Whatu Ora/Health New Zealand Waitaha/Canterbury, Christchurch 8011, New Zealand
| | - Ben Thomson
- Department of Otolaryngology, Te Whatu Ora/Health New Zealand Waitaha/Canterbury, Christchurch 8011, New Zealand
| | - Michelle Marais
- Department of Radiology, Te Whatu Ora/Health New Zealand Waitaha/Canterbury, Christchurch 8011, New Zealand
| | - Penny Hunt
- Department of Endocrinology, Te Whatu Ora/Health New Zealand Waitaha/Canterbury, Christchurch 8011, New Zealand
- University of Otago (Christchurch), Christchurch 8011, New Zealand
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11
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Halpin DM, Dickens AP, Skinner D, Murray R, Singh M, Hickman K, Carter V, Couper A, Evans A, Pullen R, Menon S, Morris T, Muellerova H, Bafadhel M, Chalmers J, Devereux G, Gibson M, Hurst JR, Jones R, Kostikas K, Quint J, Singh D, van Melle M, Wilkinson T, Price D. Identification of key opportunities for optimising the management of high-risk COPD patients in the UK using the CONQUEST quality standards: an observational longitudinal study. Lancet Reg Health Eur 2023; 29:100619. [PMID: 37131493 PMCID: PMC10149261 DOI: 10.1016/j.lanepe.2023.100619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 02/23/2023] [Accepted: 03/10/2023] [Indexed: 05/04/2023]
Abstract
Background This study compared management of high-risk COPD patients in the UK to national and international management recommendations and quality standards, including the COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST). The primary comparison was in 2019, but trends from 2000 to 2019 were also examined. Methods Patients identified in the Optimum Patient Care Research Database were categorised as newly diagnosed (≤12 months after diagnosis), already diagnosed, and potential COPD (smokers having exacerbation-like events). High-risk patients had a history of ≥2 moderate or ≥1 severe exacerbations in the previous 12 months. Findings For diagnosed patients, the median time between diagnosis and first meeting the high-risk criteria was 617 days (Q1-Q3: 3246). The use of spirometry for diagnosis increased dramatically after 2004 before plateauing and falling in recent years. In 2019, 41% (95% CI 39-44%; n = 550/1343) of newly diagnosed patients had no record of spirometry in the previous year, and 45% (95% CI 43-48%; n = 352/783) had no record of a COPD medication review within 6 months of treatment initiation or change. In 2019, 39% (n = 6893/17,858) of already diagnosed patients had no consideration of exacerbation rates, 46% (95% CI 45-47%; n = 4942/10,725) were not offered or referred for pulmonary rehabilitation, and 41% (95% CI 40-42%; n = 3026/7361) had not had a COPD review within 6 weeks of respiratory hospitalization. Interpretation Opportunities for early diagnosis of COPD patients at high risk of exacerbations are being missed. Newly and already diagnosed patients at high-risk are not being assessed or treated promptly. There is substantial scope to improve the assessment and treatment optimisation of these patients. Funding This study is conducted by the Observational & Pragmatic Research International Ltd and was co-funded by Optimum Patient Care and AstraZeneca. No funding was received by the Observational & Pragmatic Research Institute Pte Ltd (OPRI) for its contribution.
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Affiliation(s)
- David M.G. Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
- Observational and Pragmatic Research Institute, Singapore
| | | | | | | | - Mukesh Singh
- General Practice, Horse Fair Practice Group, Rugeley, Staffordshire, UK
- Keele University Medical School, Keele, UK
- Staffordshire Integrated Care System, UK
| | - Katherine Hickman
- National Asthma and COPD Audit Programme, Care Quality Improvement Department (CQID), RCP, London, UK
- Low Moor Medical Practice, Bradford, UK
- Leeds and Bradford Clinical Commissioning Groups, UK
| | | | - Amy Couper
- Observational and Pragmatic Research Institute, Singapore
| | | | - Rachel Pullen
- Observational and Pragmatic Research Institute, Singapore
| | - Shruti Menon
- Medical and Scientific Affairs, AstraZeneca, London, UK
| | - Tamsin Morris
- Medical and Scientific Affairs, AstraZeneca, London, UK
| | | | - Mona Bafadhel
- School of Immunology & Microbial Science, King's College, London, UK
| | - James Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | | | - Martin Gibson
- Salford Royal NHS Foundation Trust & Chief Executive Officer of NorthWest EHealth, UK
| | - John R. Hurst
- UCL Respiratory, University College London, London, UK
| | | | | | - Jennifer Quint
- Respiratory Epidemiology, Faculty of Medicine, National Heart & Lung Institute, London, UK
| | - Dave Singh
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK
| | - Marije van Melle
- Observational and Pragmatic Research Institute, Singapore
- Connecting Medical Dots BV, Utrecht, the Netherlands
- ORTEC, Zoetermeer, the Netherlands
| | - Tom Wilkinson
- University of Southampton Faculty of Medicine, Southampton, UK
- National Institute for Health and Care Research Southampton Biomedical Research Centre, Southampton, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore
- Optimum Patient Care, UK
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Corresponding author. Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
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12
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Dokumacı AS, Aitken FR, Sedlacik J, Bridgen P, Tomi‐Tricot R, Mooiweer R, Vecchiato K, Wilkinson T, Casella C, Giles S, Hajnal JV, Malik SJ, O'Muircheartaigh J, Carmichael DW. Simultaneous Optimization of MP2RAGE T 1 -weighted (UNI) and FLuid And White matter Suppression (FLAWS) brain images at 7T using Extended Phase Graph (EPG) Simulations. Magn Reson Med 2023; 89:937-950. [PMID: 36352772 PMCID: PMC10100108 DOI: 10.1002/mrm.29479] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/16/2022] [Accepted: 09/16/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE The MP2RAGE sequence is typically optimized for either T1 -weighted uniform image (UNI) or gray matter-dominant fluid and white matter suppression (FLAWS) contrast images. Here, the purpose was to optimize an MP2RAGE protocol at 7 Tesla to provide UNI and FLAWS images simultaneously in a clinically applicable acquisition time at <0.7 mm isotropic resolution. METHODS Using the extended phase graph formalism, the signal evolution of the MP2RAGE sequence was simulated incorporating T2 relaxation, diffusion, RF spoiling, and B1 + variability. Flip angles and TI were optimized at different TRs (TRMP2RAGE ) to produce an optimal contrast-to-noise ratio for UNI and FLAWS images. Simulation results were validated by comparison to MP2RAGE brain scans of 5 healthy subjects, and a final protocol at TRMP2RAGE = 4000 ms was applied in 19 subjects aged 8-62 years with and without epilepsy. RESULTS FLAWS contrast images could be obtained while maintaining >85% of the optimal UNI contrast-to-noise ratio. Using TI1 /TI2 /TRMP2RAGE of 650/2280/4000 ms, 6/8 partial Fourier in the inner phase-encoding direction, and GRAPPA factor = 4 in the other, images with 0.65 mm isotropic resolution were produced in <7.5 min. The contrast-to-noise ratio was around 20% smaller at TRMP2RAGE = 4000 ms compared to that at TRMP2RAGE = 5000 ms; however, the 20% shorter duration makes TRMP2RAGE = 4000 ms a good candidate for clinical applications example, pediatrics. CONCLUSION FLAWS and UNI images could be obtained in a single scan with 0.65 mm isotropic resolution, providing a set of high-contrast images and full brain coverage in a clinically applicable scan time. Images with excellent anatomical detail were demonstrated over a wide age range using the optimized parameter set.
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Affiliation(s)
- Ayşe Sıla Dokumacı
- Biomedical Engineering DepartmentSchool of Biomedical Engineering and Imaging Sciences, King's College London
LondonUnited Kingdom
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
| | - Fraser R. Aitken
- Biomedical Engineering DepartmentSchool of Biomedical Engineering and Imaging Sciences, King's College London
LondonUnited Kingdom
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
| | - Jan Sedlacik
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
- Radiology DepartmentGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Pip Bridgen
- Biomedical Engineering DepartmentSchool of Biomedical Engineering and Imaging Sciences, King's College London
LondonUnited Kingdom
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
| | - Raphael Tomi‐Tricot
- Biomedical Engineering DepartmentSchool of Biomedical Engineering and Imaging Sciences, King's College London
LondonUnited Kingdom
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
- MR Research CollaborationsSiemens Healthcare LimitedCamberleyUnited Kingdom
| | - Ronald Mooiweer
- Biomedical Engineering DepartmentSchool of Biomedical Engineering and Imaging Sciences, King's College London
LondonUnited Kingdom
- MR Research CollaborationsSiemens Healthcare LimitedCamberleyUnited Kingdom
| | - Katy Vecchiato
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
- Department of Forensic and Neurodevelopmental SciencesInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUnited Kingdom
- Centre for the Developing BrainSchool of Biomedical Engineering and Imaging Sciences, King's College LondonLondonUnited Kingdom
| | - Tom Wilkinson
- Biomedical Engineering DepartmentSchool of Biomedical Engineering and Imaging Sciences, King's College London
LondonUnited Kingdom
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
| | - Chiara Casella
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
- Centre for the Developing BrainSchool of Biomedical Engineering and Imaging Sciences, King's College LondonLondonUnited Kingdom
| | - Sharon Giles
- Biomedical Engineering DepartmentSchool of Biomedical Engineering and Imaging Sciences, King's College London
LondonUnited Kingdom
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
| | - Joseph V. Hajnal
- Biomedical Engineering DepartmentSchool of Biomedical Engineering and Imaging Sciences, King's College London
LondonUnited Kingdom
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
| | - Shaihan J. Malik
- Biomedical Engineering DepartmentSchool of Biomedical Engineering and Imaging Sciences, King's College London
LondonUnited Kingdom
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
| | - Jonathan O'Muircheartaigh
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
- Department of Forensic and Neurodevelopmental SciencesInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUnited Kingdom
- Centre for the Developing BrainSchool of Biomedical Engineering and Imaging Sciences, King's College LondonLondonUnited Kingdom
- MRC Centre for Neurodevelopmental Disorders, King's College LondonLondonUnited Kingdom
| | - David W. Carmichael
- Biomedical Engineering DepartmentSchool of Biomedical Engineering and Imaging Sciences, King's College London
LondonUnited Kingdom
- London Collaborative Ultra high field System (LoCUS)LondonUnited Kingdom
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DeNucci G, Wilkinson T, Sverdloff C, Babadopulos T, Woodcock A, Shute J, Renato Guazelli P, Gerbase LF, Mourão PAS, Singh D, van Haren FMP, Page C. Inhaled nebulised unfractionated heparin (UFH) for the treatment of hospitalised patients with COVID-19: A randomised controlled pilot study. Pulm Pharmacol Ther 2023; 80:102212. [PMID: 36990381 PMCID: PMC10064078 DOI: 10.1016/j.pupt.2023.102212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/07/2023] [Accepted: 03/19/2023] [Indexed: 03/29/2023]
Abstract
There is a strong scientific rationale to use nebulised unfractionated heparin (UFH) in treating patients with COVID-19. This pilot study investigated whether nebulised UFH was safe and had any impact on mortality, length of hospitalisation and clinical progression, in the treatment of hospitalised patients with COVID-19. This parallel group, open label, randomised trial included adult patients with confirmed SARS-CoV-2 infection admitted to two hospitals in Brazil. One hundred patients were planned to be randomised to either "standard of care" (SOC) or SOC plus nebulized UFH. The trial was stopped after randomisation of 75 patients due to falling COVID-19 hospitalisation rates. Significance tests were 1-sided test (10% significance level). The key analysis populations were intention to treat (ITT) and modified ITT (mITT) which excluded (from both arms) subjects admitted to ITU or who died within 24 h of randomisation. In the ITT population (n = 75), mortality was numerically lower for nebulised UFH (6 out of 38 patients; 15.8%) versus SOC (10 out of 37 patients; 27.0%), but not statistically significant; odds ratio (OR) 0.51, p = 0.24. However, in the mITT population, nebulised UFH reduced mortality (OR 0.2, p = 0.035). Length of hospital stay was similar between groups, but at day 29, there was a greater improvement in ordinal score following treatment with UFH in the ITT and mITT populations (p = 0.076 and p = 0.012 respectively), while mechanical ventilation rates were lower with UFH in the mITT population (OR 0.31; p = 0.08). Nebulised UFH did not cause any significant adverse events. In conclusion, nebulised UFH added to SOC in hospitalised patients with COVID-19 was well tolerated and showed clinical benefit, particularly in patients who received at least 6 doses of heparin. This trial was funded by The J.R. Moulton Charity Trust and registered under REBEC RBR-8r9hy8f (UTN code: U1111-1263-3136).
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Affiliation(s)
- Gilberto DeNucci
- Department of Pharmacology, University of Sao Paulo, Brazil; Department of Pharmacology, University of Campinas, Brazil
| | - Tom Wilkinson
- Department of Respiratory Medicine, University of Southampton, UK
| | | | | | - Ashley Woodcock
- Manchester Academic Health Sciences Centre, Medicines Evaluation Unit, University of Manchester, UK
| | - Jan Shute
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, UK
| | | | | | - Paulo A S Mourão
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Brazil
| | - Dave Singh
- Manchester Academic Health Sciences Centre, Medicines Evaluation Unit, University of Manchester, UK
| | - Frank M P van Haren
- Australian National University, College of Health and Medicine, Canberra, Australia; Intensive Care Unit, St George Hospital, Sydney, Australia
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, UK
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Wilkinson T, Hunt P, McHaffie A. Two Cases of Adrenal Malignancy With Macroscopic Fat. JCEM Case Rep 2023; 1:luac029. [PMID: 37908270 PMCID: PMC10578380 DOI: 10.1210/jcemcr/luac029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Indexed: 11/02/2023]
Abstract
The presence of macroscopic fat on computed tomography (CT) imaging has been traditionally regarded as an indication that an adrenal lesion is likely to be a benign myelolipoma, for which further investigation is not usually required. Two cases are described where an adrenal lesion was eventually found to be malignant on histology (adrenocortical carcinoma in the first case, undifferentiated sarcoma in the second case), despite the presence of macroscopic fat on CT. In both cases there were other clinical and radiological indicators of potential malignant pathology. These cases add to increasing awareness in the literature that malignant adrenal tumors may rarely contain macroscopic fat, emphasizing a need for clinical vigilance.
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Affiliation(s)
- Tom Wilkinson
- Department of Endocrinology, Christchurch Hospital, Christchurch 8011, New Zealand
| | - Penny Hunt
- Department of Endocrinology, Christchurch Hospital, Christchurch 8011, New Zealand
- Department of Medicine, University of Otago (Christchurch), Christchurch 8011, New Zealand
| | - Alexandra McHaffie
- Department of Radiology, Christchurch Hospital, Christchurch 8011, New Zealand
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15
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Monk PD, Evans RA, Tear VJ, Brookes JL, Batten T, Mankowski M, Djukanovic R, Holgate ST, Brightling C, Wilkinson T. LB1533. Impact of Treatment of Hospitalised COVID-19 Patients With Inhaled Interferon Beta-1a (SNG001) on Long COVID Symptoms: Results From the SPRINTER trial. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
People with post-COVID conditions can have a wide range of symptoms lasting months and it can affect as many as one in five infected people. Interferon beta (IFN-β) is key in host defence against viruses but can be suppressed by virus or host factors locally at the site of infection. Inhalation of SNG001 (IFN-β-1a nebuliser solution) aims to restore lung IFN-β levels. SPRINTER (NCT04732949) was a RCT of inhaled interferon beta in hospitalised COVID-19. There was no effect of SNG001 on the primary endpoints of time to discharge or recovery most likely due to improvements in the standard of care. However, there was an encouraging signal for the key secondary endpoint of prevention of progression to severe disease or death (ITT 26% relative risk reduction [RRR]; Odds Ratio [95% CI]: 0.71 [0.44, 1.15]; Per Protocol 36% RRR; OR 0.63 [0.35, 1.13]). Post hoc analyses showed enhanced effects favouring SNG001 in subgroups at higher risk of progression. We report on the impact of SNG001 on long COVID symptoms in SPRINTER.
Methods
Patients requiring low-flow oxygen were randomized to receive SNG001 (314) or placebo (309) once daily for 14 days, plus standard-of-care. Long COVID symptoms were assessed as a secondary endpoint at follow-up visits via telephone/video call on Day 60 and Day 90. The following patient reported outcome (PRO) measures were also assessed: General Anxiety Disorder 7 Questionnaire (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Functional Assessment of Chronic Illness Therapy (FACIT) - Fatigue Scale and Brief Pain Inventory (Short Form).
Results
When compared to placebo, SNG001 reduced the relative risk of common symptoms of long COVID (fatigue/malaise [RRR=35.4%]; dyspnoea [RRR=28.3%]; loss of smell and/or taste [RRR=61.4%]). Analysis of the PROs is ongoing.
Assessment of COVID symptoms at Day 60 and 90 follow up visits
Effect of SNG001 treatment on long COVID symptoms
Conclusion
Long COVID can leave patients with lingering cognitive, respiratory, and functional symptoms months after a SARS-CoV-2 infection. Given the shift from pandemic to endemic status for COVID-19 and the need for new treatments then these findings, suggesting SNG001 may be impacting common long COVID symptoms, provide additional support for the further investigation of SNG001.
Disclosures
Phillip D. Monk, PhD, Synairgen Plc (Employed by Synairgen Research Ltd which is a subsidiary of Synairgen Plc, Stocks/Bonds): Board Member|Synairgen Plc (Employed by Synairgen Research Ltd which is a subsidiary of Synairgen Plc, Stocks/Bonds): Stocks/Bonds Victoria J. Tear, PhD, Synairgen Plc (Employed by Synairgen Research Ltd which is a subsidiary of Synairgen Plc, Stocks/Bonds): Stocks/Bonds Jody L. Brookes, BSc, Synairgen Plc (Employed by Synairgen Research Ltd which is a subsidiary of Synairgen Plc, Stocks/Bonds): Stocks/Bonds Marcin Mankowski, MD, MFPM (Dis), CytoDyn: Advisor/Consultant|Entasis: Advisor/Consultant|ImmuPharma: Advisor/Consultant|Menarini: Advisor/Consultant|Pfizer: Advisor/Consultant|Synairgen: Advisor/Consultant|Venatorx: Advisor/Consultant Ratko Djukanovic, MD, Synairgen: Advisor/Consultant|Synairgen: Honoraria|Synairgen: Stocks/Bonds Stephen T. Holgate, FMedSci, MD, Synairgen: Board Member|Synairgen: Non executive board director, patent on inhaled interferon beta|Synairgen: Stocks/Bonds chris brightling, FMedSci, Synairgen: Advisor/Consultant|Synairgen: Grant/Research Support Tom Wilkinson, PhD, PhD, AZ: Grant/Research Support|AZ: Honoraria|My mhealth: Board Member|My mhealth: Ownership Interest|My mhealth: Stocks/Bonds|Synairgen: Grant/Research Support|Synairgen: Honoraria.
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Affiliation(s)
- Phillip D Monk
- Synairgen Research Limited , Southampton, England , United Kingdom
| | - Rachael A Evans
- University of Leicester , Leicester, England , United Kingdom
| | - Victoria J Tear
- Synairgen Research Limited , Southampton, England , United Kingdom
| | - Jody L Brookes
- Synairgen Research Ltd , Southampton, England , United Kingdom
| | - Toby Batten
- Veramed Ltd , Twickenham, England , United Kingdom
| | | | - Ratko Djukanovic
- Faculty of Medicine, University of Southampton , SOUTHAMPTON, England , United Kingdom
| | | | | | - Tom Wilkinson
- University of Southampton , Southampton, England , United Kingdom
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Leitão D, Tomi-Tricot R, Bridgen P, Wilkinson T, Liebig P, Gumbrecht R, Ritter D, Giles SL, Baburamani A, Sedlacik J, Hajnal JV, Malik SJ. Parallel transmit pulse design for saturation homogeneity (PUSH) for magnetization transfer imaging at 7T. Magn Reson Med 2022; 88:180-194. [PMID: 35266204 PMCID: PMC9315051 DOI: 10.1002/mrm.29199] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Received: 09/09/2021] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE This work proposes a novel RF pulse design for parallel transmit (pTx) systems to obtain uniform saturation of semisolid magnetization for magnetization transfer (MT) contrast in the presence of transmit field B1+ inhomogeneities. The semisolid magnetization is usually modeled as being purely longitudinal, with the applied B1+ field saturating but not rotating its magnetization; thus, standard pTx pulse design methods do not apply. THEORY AND METHODS Pulse design for saturation homogeneity (PUSH) optimizes pTx RF pulses by considering uniformity of root-mean squared B1+ , B1rms , which relates to the rate of semisolid saturation. Here we considered designs consisting of a small number of spatially non-selective sub-pulses optimized over either a single 2D plane or 3D. Simulations and in vivo experiments on a 7T Terra system with an 8-TX Nova head coil in five subjects were carried out to study the homogenization of B1rms and of the MT contrast by acquiring MT ratio maps. RESULTS Simulations and in vivo experiments showed up to six and two times more uniform B1rms compared to circular polarized (CP) mode for 2D and 3D optimizations, respectively. This translated into 4 and 1.25 times more uniform MT contrast, consistently for all subjects, where two sub-pulses were enough for the implementation and coil used. CONCLUSION The proposed PUSH method obtains more uniform and higher MT contrast than CP mode within the same specific absorption rate (SAR) budget.
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Affiliation(s)
- David Leitão
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | | | - Pip Bridgen
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Tom Wilkinson
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | | | | | | | - Sharon L Giles
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Ana Baburamani
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Jan Sedlacik
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Joseph V Hajnal
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Shaihan J Malik
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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17
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Meiwald A, Gara-Adams R, Rowlandson A, Ma Y, Watz H, Ichinose M, Scullion J, Wilkinson T, Bhutani M, Weston G, Adams EJ. Qualitative Validation of COPD Evidenced Care Pathways in Japan, Canada, England, and Germany: Common Barriers to Optimal COPD Care. Int J Chron Obstruct Pulmon Dis 2022; 17:1507-1521. [PMID: 35801119 PMCID: PMC9255283 DOI: 10.2147/copd.s360983] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. A comprehensive and detailed understanding of COPD care pathways from pre-diagnosis to acute care is required to understand the common barriers to optimal COPD care across diverse health systems. Methods Country-specific COPD care pathways were created for four high-income countries using international recommendations and country-specific guidelines, then populated with published epidemiological, clinical, and economic data. To refine and validate the pathways, semi-structured interviews using pre-prepared discussion guides and country-specific pathway maps were held with twenty-four primary and secondary care respiratory healthcare professionals. Thematic analysis was then performed on the interview transcripts. Results The COPD care pathway showed broad consistency across the countries. Three key themes relating to barriers in optimal COPD management were identified across the countries: journey to diagnosis, treatment, and the impact of COVID-19. Common barriers included presentation to healthcare with advanced COPD, low COPD consideration, and sub-optimal acute and chronic disease management. COVID-19 has negatively impacted disease management across the pathway but presents opportunities to retain virtual consultations. Structural factors such as insurance and short duration of appointments also impacted the diagnosis and management of COPD. Conclusion COPD is an important public health issue that needs urgent prioritization. The use of Evidenced Care Pathways with decision-makers can facilitate evidence-based decision making on interventions and policies to improve care and outcomes for patients and reduce unnecessary resource use and associated costs for the healthcare provider/payer.
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Affiliation(s)
| | | | | | - Yixuan Ma
- Aquarius Population Health, London, UK
| | - Henrik Watz
- Pulmonary Research Institute, LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Schleswig-Holstein, Germany
| | | | | | - Tom Wilkinson
- Faculty of Medicine, Southampton University, Southampton, Hampshire, UK
- Respiratory and Allergy, NIHR Southampton Biomedical Research Centre, Southampton, Hampshire, UK
| | - Mohit Bhutani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Elisabeth J Adams
- Aquarius Population Health, London, UK
- Correspondence: Elisabeth J Adams, Aquarius Population Health, Unit 29 Tileyard Studios, London, N7 9AH, UK, Tel +44 (0)207 993 2930, Email
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18
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Horsley AR, Pearmain L, Knight S, Schindler N, Wang R, Bennett M, Robey RC, Davies JC, Djukanović R, Heaney LG, Hussell T, Marciniak SJ, McGarvey LP, Porter J, Wilkinson T, Brightling C, Ho LP. Large scale clinical trials: lessons from the COVID-19 pandemic. BMJ Open Respir Res 2022; 9:9/1/e001226. [PMID: 35701071 PMCID: PMC9198385 DOI: 10.1136/bmjresp-2022-001226] [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] [Received: 02/06/2022] [Accepted: 05/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has presented substantial new challenges to clinical and research teams. Our objective was to analyse the experience of investigators and research delivery staff regarding the research response to COVID-19 in order to identify these challenges as well as solutions for future pandemic planning. METHODS We conducted a survey of diverse research staff involved in delivery of COVID-19 clinical trials across the UK. This was delivered online across centres linked to the NIHR Respiratory Translational Research Collaboration. Responses were analysed using a formal thematic analysis approach to identify common themes and recommendations. RESULTS 83 survey participants from ten teaching hospitals provided 922 individual question responses. Respondents were involved in a range of research delivery roles but the largest cohort (60%) was study investigators. A wide range of research experiences were captured, including early and late phase trials. Responses were coded into overarching themes. Among common observations, complex protocols without adaptation to a pandemic were noted to have hampered recruitment. Recommendations included the need to develop and test pandemic-specific protocols, and make use of innovations in information technology. Research competition needs to be avoided and drug selection processes should be explicitly transparent. CONCLUSIONS Delivery of clinical trials, particularly earlier phase trials, in a pandemic clinical environment is highly challenging, and was reactive rather than anticipatory. Future pandemic studies should be designed and tested in advance, making use of pragmatic study designs as far as possible and planning for integration between early and later phase trials and regulatory frameworks.
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Affiliation(s)
- Alex R Horsley
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester Faculty of Medical and Human Sciences, Manchester, UK
| | - Laurence Pearmain
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester Faculty of Medical and Human Sciences, Manchester, UK.,Division of Diabetes, Endocrinology and Gastroenterology, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - Sean Knight
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester Faculty of Medical and Human Sciences, Manchester, UK.,Department of Respiratory Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Nick Schindler
- Institute of Continuing Education, University of Cambridge, Cambridge, UK.,Department of Paediatrics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Ran Wang
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester Faculty of Medical and Human Sciences, Manchester, UK
| | - Miriam Bennett
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester Faculty of Medical and Human Sciences, Manchester, UK
| | - Rebecca C Robey
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester Faculty of Medical and Human Sciences, Manchester, UK
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Ratko Djukanović
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton School of Medicine, Southampton, UK
| | - Liam G Heaney
- Centre of Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Tracy Hussell
- Manchester Centre for Infection and Inflammation Research, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - Stefan J Marciniak
- Cambridge Institute for Medical Research, University of Cambridge, Cambridge, UK.,Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Lorcan P McGarvey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Joanna Porter
- Centre for Inflammation & Tissue Repair, University College London Division of Medicine, London, UK.,Interstitial Lung Disease Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tom Wilkinson
- Clinical and Experimental Medicine, University of Southampton School of Medicine, Southampton, UK
| | - Chris Brightling
- Institute of Lung Health, University of Leicester, Leicester, UK
| | - Ling-Pei Ho
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, Oxford, UK.,Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
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19
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Tavares N, Jarrett N, Wilkinson T, Hunt K. Clinician Perspectives on How to Hold Earlier Discussions About Palliative and End-of-Life Care With Chronic Obstructive Pulmonary Disease Patients: A Qualitative Study. J Hosp Palliat Nurs 2022; 24:E101-E107. [PMID: 35334479 DOI: 10.1097/njh.0000000000000858] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Chronic obstructive pulmonary disease is associated with progressive symptoms and increased treatment burden, especially at the end of life. However, most patients do not receive palliative care until late in their lives or discuss their end-of-life preferences with clinicians. This study explored clinicians' perspectives on the timing and nature of palliative care discussions. Qualitative interviews were conducted with 7 physicians and 7 nurses working in primary and secondary care settings. Data were analyzed using a thematic analysis. Participants advocated for early, gradual, and informed palliative and future care discussions, because these discussions were thought to be less traumatic and better accepted by patients. Despite this, patient- and clinician-related barriers severely affected clinicians' ability to start discussions at earlier stages. Participants felt many patients were not ready for these discussions and feared damaging hope if the subject was broached. Therefore, clinicians delayed discussions until patients approached the end of life. Stand-alone conversations about and near the end of life were described as current practice; however, clinicians believed these discussions reduced patients' hope and were potentially upsetting. Instead, individualized early, regular, and gradual discussions about immediate and long-term care plans were thought to be less negative and be better accepted.
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20
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Killingley B, Mann AJ, Kalinova M, Boyers A, Goonawardane N, Zhou J, Lindsell K, Hare SS, Brown J, Frise R, Smith E, Hopkins C, Noulin N, Löndt B, Wilkinson T, Harden S, McShane H, Baillet M, Gilbert A, Jacobs M, Charman C, Mande P, Nguyen-Van-Tam JS, Semple MG, Read RC, Ferguson NM, Openshaw PJ, Rapeport G, Barclay WS, Catchpole AP, Chiu C. Safety, tolerability and viral kinetics during SARS-CoV-2 human challenge in young adults. Nat Med 2022; 28:1031-1041. [PMID: 35361992 DOI: 10.1038/s41591-022-01780-9] [Citation(s) in RCA: 214] [Impact Index Per Article: 107.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 03/09/2022] [Indexed: 12/16/2022]
Abstract
Since its emergence in 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused hundreds of millions of cases and continues to circulate globally. To establish a novel SARS-CoV-2 human challenge model that enables controlled investigation of pathogenesis, correlates of protection and efficacy testing of forthcoming interventions, 36 volunteers aged 18-29 years without evidence of previous infection or vaccination were inoculated with 10 TCID50 of a wild-type virus (SARS-CoV-2/human/GBR/484861/2020) intranasally in an open-label, non-randomized study (ClinicalTrials.gov identifier NCT04865237 ; funder, UK Vaccine Taskforce). After inoculation, participants were housed in a high-containment quarantine unit, with 24-hour close medical monitoring and full access to higher-level clinical care. The study's primary objective was to identify an inoculum dose that induced well-tolerated infection in more than 50% of participants, with secondary objectives to assess virus and symptom kinetics during infection. All pre-specified primary and secondary objectives were met. Two participants were excluded from the per-protocol analysis owing to seroconversion between screening and inoculation, identified post hoc. Eighteen (~53%) participants became infected, with viral load (VL) rising steeply and peaking at ~5 days after inoculation. Virus was first detected in the throat but rose to significantly higher levels in the nose, peaking at ~8.87 log10 copies per milliliter (median, 95% confidence interval (8.41, 9.53)). Viable virus was recoverable from the nose up to ~10 days after inoculation, on average. There were no serious adverse events. Mild-to-moderate symptoms were reported by 16 (89%) infected participants, beginning 2-4 days after inoculation, whereas two (11%) participants remained asymptomatic (no reportable symptoms). Anosmia or dysosmia developed more slowly in 15 (83%) participants. No quantitative correlation was noted between VL and symptoms, with high VLs present even in asymptomatic infection. All infected individuals developed serum spike-specific IgG and neutralizing antibodies. Results from lateral flow tests were strongly associated with viable virus, and modeling showed that twice-weekly rapid antigen tests could diagnose infection before 70-80% of viable virus had been generated. Thus, with detailed characterization and safety analysis of this first SARS-CoV-2 human challenge study in young adults, viral kinetics over the course of primary infection with SARS-CoV-2 were established, with implications for public health recommendations and strategies to affect SARS-CoV-2 transmission. Future studies will identify the immune factors associated with protection in those participants who did not develop infection or symptoms and define the effect of prior immunity and viral variation on clinical outcome.
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Affiliation(s)
- Ben Killingley
- Department of Infectious Diseases, University College London Hospital, London, UK
| | | | | | | | | | - Jie Zhou
- Department of Infectious Disease, Imperial College London, London, UK
| | - Kate Lindsell
- UK Vaccine Taskforce, Department for Business, Energy and Industrial Strategy, London, UK
| | - Samanjit S Hare
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Jonathan Brown
- Department of Infectious Disease, Imperial College London, London, UK
| | - Rebecca Frise
- Department of Infectious Disease, Imperial College London, London, UK
| | - Emma Smith
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Claire Hopkins
- ENT Department, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | | | | | - Tom Wilkinson
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, and NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Stephen Harden
- Department of Radiology, Southampton General Hospital, Southampton, UK
| | - Helen McShane
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Anthony Gilbert
- UK Vaccine Taskforce, Department for Business, Energy and Industrial Strategy, London, UK
| | - Michael Jacobs
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK
| | - Christine Charman
- UK Vaccine Taskforce, Department for Business, Energy and Industrial Strategy, London, UK
| | - Priya Mande
- UK Vaccine Taskforce, Department for Business, Energy and Industrial Strategy, London, UK
| | - Jonathan S Nguyen-Van-Tam
- Division of Epidemiology and Public Health, University of Nottingham School of Medicine, Nottingham, UK
| | - Malcolm G Semple
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool; Respiratory Department, Alder Hey Children's Hospital, Liverpool, UK
| | - Robert C Read
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, and NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Neil M Ferguson
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Peter J Openshaw
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Garth Rapeport
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Wendy S Barclay
- Department of Infectious Disease, Imperial College London, London, UK
| | | | - Christopher Chiu
- Department of Infectious Disease, Imperial College London, London, UK.
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21
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Fong WCG, Rafiq I, Harvey M, Stanescu S, Ainsworth B, Varkonyi-Sepp J, Mistry H, Kyyaly MA, Barber C, Freeman A, Wilkinson T, Djukanovic R, Dennison P, Haitchi HM, Kurukulaaratchy RJ. The Detrimental Clinical Associations of Anxiety and Depression with Difficult Asthma Outcomes. J Pers Med 2022; 12:jpm12050686. [PMID: 35629109 PMCID: PMC9142921 DOI: 10.3390/jpm12050686] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 03/27/2022] [Accepted: 04/06/2022] [Indexed: 01/04/2023] Open
Abstract
Difficult asthma describes asthma in which comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence impede good asthma control. The association of anxiety and depression with difficult asthma outcomes (exacerbations, hospital admissions, asthma control, etc.) is unclear. This study assessed the clinical associations of anxiety and depression with difficult asthma outcomes in patients with a specialist diagnosis of difficult asthma. Using real-world data, we retrospectively phenotyped patients from the Wessex Asthma Cohort of Difficult Asthma (N = 441) using clinical diagnoses of anxiety and depression against those without anxiety or depression (controls). Additionally, we stratified patients by severity of psychological distress using the Hospital Anxiety and Depression Scale (HADS). We found that depression and/or anxiety were reported in 43.1% of subjects and were associated with worse disease-related questionnaire scores. Each psychological comorbidity group showed differential associations with difficult asthma outcomes. Anxiety alone (7.9%) was associated with dysfunctional breathing and more hospitalisations [anxiety, median (IQR): 0 (2) vs. controls: 0 (0)], while depression alone (11.6%) was associated with obesity and obstructive sleep apnoea. The dual anxiety and depression group (23.6%) displayed multimorbidity, worse asthma outcomes, female predominance and earlier asthma onset. Worse HADS-A scores in patients with anxiety were associated with worse subjective outcomes (questionnaire scores), while worse HADS-D scores in patients with depression were associated with worse objective (ICU admissions and maintenance oral corticosteroid requirements) and subjective outcomes. In conclusion, anxiety and depression are common in difficult asthma but exert differential detrimental effects. Difficult asthma patients with dual anxiety and depression experience worse asthma outcomes alongside worse measures of psychological distress. There is a severity-gradient association of HADS scores with worse difficult asthma outcomes. Collectively, our findings highlight the need for holistic, multidisciplinary approaches that promote early identification and management of anxiety and depression in difficult asthma patients.
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Affiliation(s)
- Wei Chern Gavin Fong
- School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK; (W.C.G.F.); (J.V.-S.); (H.M.); (M.A.K.); (A.F.); (T.W.); (R.D.); (H.M.H.)
- David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight PO30 5TG, UK
| | - Ishmail Rafiq
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK;
| | - Matthew Harvey
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
| | - Sabina Stanescu
- Department of Psychology, University of Southampton, Southampton SO17 1BJ, UK;
| | - Ben Ainsworth
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
- Department of Psychology, University of Bath, Bath BA2 7AY, UK
| | - Judit Varkonyi-Sepp
- School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK; (W.C.G.F.); (J.V.-S.); (H.M.); (M.A.K.); (A.F.); (T.W.); (R.D.); (H.M.H.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK;
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
| | - Heena Mistry
- School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK; (W.C.G.F.); (J.V.-S.); (H.M.); (M.A.K.); (A.F.); (T.W.); (R.D.); (H.M.H.)
- David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight PO30 5TG, UK
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
| | - Mohammed Aref Kyyaly
- School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK; (W.C.G.F.); (J.V.-S.); (H.M.); (M.A.K.); (A.F.); (T.W.); (R.D.); (H.M.H.)
- David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight PO30 5TG, UK
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
| | - Clair Barber
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
| | - Anna Freeman
- School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK; (W.C.G.F.); (J.V.-S.); (H.M.); (M.A.K.); (A.F.); (T.W.); (R.D.); (H.M.H.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK;
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
| | - Tom Wilkinson
- School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK; (W.C.G.F.); (J.V.-S.); (H.M.); (M.A.K.); (A.F.); (T.W.); (R.D.); (H.M.H.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK;
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
| | - Ratko Djukanovic
- School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK; (W.C.G.F.); (J.V.-S.); (H.M.); (M.A.K.); (A.F.); (T.W.); (R.D.); (H.M.H.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK;
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
| | - Paddy Dennison
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
- Department of Respiratory Medicine, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Hans Michael Haitchi
- School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK; (W.C.G.F.); (J.V.-S.); (H.M.); (M.A.K.); (A.F.); (T.W.); (R.D.); (H.M.H.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK;
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
| | - Ramesh J. Kurukulaaratchy
- School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK; (W.C.G.F.); (J.V.-S.); (H.M.); (M.A.K.); (A.F.); (T.W.); (R.D.); (H.M.H.)
- David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight PO30 5TG, UK
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK;
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (M.H.); (B.A.); (C.B.); (P.D.)
- Correspondence:
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22
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Byrne S, Schughart M, Carolan JC, Gaffney M, Thorpe P, Malloch G, Wilkinson T, McNamara L. Genome sequence of the English grain aphid, Sitobion avenae and its endosymbiont Buchnera aphidicola. G3 Genes|Genomes|Genetics 2022; 12:6456306. [PMID: 34878113 PMCID: PMC9210274 DOI: 10.1093/g3journal/jkab418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022]
Abstract
The English grain aphid, Sitobion avenae, is a major agricultural pest of wheat, barley and oats, and one of the principal vectors of barley yellow dwarf virus leading to significant reductions in grain yield, annually. Emerging resistance to and increasing regulation of insecticides has resulted in limited options for their control. Using PacBio HiFi data, we have produced a high-quality draft assembly of the S. avenae genome; generating a primary assembly with a total assembly size of 475.7 Mb, and an alternate assembly with a total assembly size of 430.8 Mb. Our primary assembly was highly contiguous with only 326 contigs and a contig N50 of 15.95 Mb. Assembly completeness was estimated at 97.7% using BUSCO analysis and 31,007 and 29,037 protein-coding genes were predicted from the primary and alternate assemblies, respectively. This assembly, which is to our knowledge the first for an insecticide resistant clonal lineage of English grain aphid, will provide novel insight into the molecular and mechanistic determinants of resistance and will facilitate future research into mechanisms of viral transmission and aphid behavior.
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Affiliation(s)
- Stephen Byrne
- Teagasc, Crop Science Department, Carlow R93 XE12, Ireland
| | - Maximilian Schughart
- Teagasc, Crop Science Department, Carlow R93 XE12, Ireland
- School of Biology and Environmental Science, University College Dublin, Dublin 4, Ireland
| | - James C Carolan
- Department of Biology, Maynooth University, Maynooth, Co. Kildare, W23 F2H6, Ireland
| | | | - Peter Thorpe
- School of Medicine, University of St Andrews, North Haugh, KY16 9TF St Andrews, UK
| | - Gaynor Malloch
- The James Hutton Institute, Invergowrie, Dundee DD2 5DA, UK
| | - Tom Wilkinson
- School of Biology and Environmental Science, University College Dublin, Dublin 4, Ireland
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23
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Burke H, Freeman A, O'Regan P, Wysocki O, Freitas A, Dushianthan A, Celinski M, Batchelor J, Phan H, Borca F, Sheard N, Williams S, Watson A, Fitzpatrick P, Landers D, Wilkinson T. Biomarker identification using dynamic time warping analysis: a longitudinal cohort study of patients with COVID-19 in a UK tertiary hospital. BMJ Open 2022; 12:e050331. [PMID: 35168965 PMCID: PMC8852240 DOI: 10.1136/bmjopen-2021-050331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 01/27/2022] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES COVID-19 is a heterogeneous disease, and many reports have described variations in demographic, biochemical and clinical features at presentation influencing overall hospital mortality. However, there is little information regarding longitudinal changes in laboratory prognostic variables in relation to disease progression in hospitalised patients with COVID-19. DESIGN AND SETTING This retrospective observational report describes disease progression from symptom onset, to admission to hospital, clinical response and discharge/death among patients with COVID-19 at a tertiary centre in South East England. PARTICIPANTS Six hundred and fifty-one patients treated for SARS-CoV-2 between March and September 2020 were included in this analysis. Ethical approval was obtained from the HRA Specific Review Board (REC 20/HRA/2986) for waiver of informed consent. RESULTS The majority of patients presented within 1 week of symptom onset. The lowest risk patients had low mortality (1/45, 2%), and most were discharged within 1 week after admission (30/45, 67%). The highest risk patients, as determined by the 4C mortality score predictor, had high mortality (27/29, 93%), with most dying within 1 week after admission (22/29, 76%). Consistent with previous reports, most patients presented with high levels of C reactive protein (CRP) (67% of patients >50 mg/L), D-dimer (98%>upper limit of normal (ULN)), ferritin (65%>ULN), lactate dehydrogenase (90%>ULN) and low lymphocyte counts (81% CONCLUSIONS Serial measurement of routine blood tests may be a useful prognostic tool for monitoring treatment response in hospitalised patients with COVID-19. Changes in other biochemical parameters often included in a 'COVID-19 bundle' did not show significant association with outcome, suggesting there may be limited clinical benefit of serial sampling. This may have direct clinical utility in the context of escalating healthcare costs of the pandemic.
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Affiliation(s)
- Hannah Burke
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anna Freeman
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul O'Regan
- Digital Experimental Cancer Medicine Team, Cancer Biomarker Centre, Cancer Research UK Manchester Institute, The University of Manchester, Manchester, UK
| | - Oskar Wysocki
- Digital Experimental Cancer Medicine Team, Cancer Biomarker Centre, Cancer Research UK Manchester Institute, The University of Manchester, Manchester, UK
| | - Andre Freitas
- Digital Experimental Cancer Medicine Team, Cancer Biomarker Centre, Cancer Research UK Manchester Institute, The University of Manchester, Manchester, UK
| | | | | | - James Batchelor
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Hang Phan
- Clinical Informatics Research Unit, University of Southampton Faculty of Medicine, Southampton, UK
- University of Southampton, Southampton, UK
| | - Florina Borca
- Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Natasha Sheard
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sarah Williams
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alastair Watson
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Fitzpatrick
- University of Manchester, Cancer Biomarker Centre, Cancer Research UK Manchester Institute, Manchester, UK
| | - Dónal Landers
- Digital Experimental Cancer Medicine Team, University of Manchester, Cancer Biomarker Centre, Cancer Research UK Manchester Institute, Alderley Edge, Cheshire, UK
| | - Tom Wilkinson
- Faculty of Medicine, University of Southampton, Southampton, UK
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Wilkinson T. Subcutaneous interferon beta-1a in COVID-19: raking the ashes of an intervention trial. Lancet Respir Med 2021; 9:1344-1345. [PMID: 34672951 PMCID: PMC8523115 DOI: 10.1016/s2213-2600(21)00412-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 12/05/2022]
Affiliation(s)
- Tom Wilkinson
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK.
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Abstract
α1-Antitrypsin deficiency (AATD) has been historically under-recognised and under-diagnosed; recently it has begun to receive greater interest in terms of attempts at deeper elucidation of pathology and treatment options. However, the concept of disease phenotypes within AATD (emphysema, chronic bronchitis, bronchiectasis or a combination of phenotypes) has not been proposed or studied. Of the three neutrophil serine proteases, neutrophil elastase was historically believed to be the sole contributor to disease pathology in AATD. Recently, Proteinase-3 has been increasingly studied as an equal, if not greater, contributor to the disease process. Cathepsin G, however, has not been extensively evaluated in this area. Matrix metalloproteinases have also been mentioned in the pathogenesis of AATD but have not been widely explored. This article considers the available evidence for differential protease activity in patients with AATD, including the contribution to distinct phenotypes of the disease. Owing to limited literature in this area, extrapolations from studies of other chronic lung diseases with similar phenotypes, including COPD and bronchiectasis, have been made. We consider a new framework of understanding defined by protease-driven endotypes of disease which may lead to new opportunities for precision medicine.
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Affiliation(s)
- Aishath Fazleen
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Tom Wilkinson
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
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26
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Mistry H, Ajsivinac Soberanis HM, Kyyaly MA, Azim A, Barber C, Knight D, Newell C, Haitchi HM, Wilkinson T, Howarth P, Seumois G, Vijayanand P, Arshad SH, Kurukulaaratchy RJ. The Clinical Implications of Aspergillus Fumigatus Sensitization in Difficult-To-Treat Asthma Patients. J Allergy Clin Immunol Pract 2021; 9:4254-4267.e10. [PMID: 34534722 DOI: 10.1016/j.jaip.2021.08.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fungal sensitivity has been associated with severe asthma outcomes. However, the clinical implication of Aspergillus fumigatus sensitization in difficult-to-treat (or difficult) asthma is unclear. OBJECTIVES To characterize the clinical implications of A fumigatus sensitization in a large difficult asthma cohort. METHODS Participants who underwent both skin prick and specific IgE testing to A fumigatus (n = 318) from the longitudinal real-life Wessex AsThma CoHort of difficult asthma, United Kingdom, were characterized by A fumigatus sensitization (either positive skin prick test result or specific IgE) and allergic bronchopulmonary aspergillosis status using clinical/pathophysiological disease measures. RESULTS A fumigatus sensitization was found in 23.9% (76 of 318) of patients with difficult asthma. Compared with A fumigatus nonsensitized subjects, those with sensitization were significantly more often male (50% vs 31%), older (58 years) with longer asthma duration (33 years), higher maintenance oral corticosteroid (39.7%) and asthma biologic use (27.6%), raised current/maximum log10 total IgE+1 (2.43/2.72 IU/L), worse prebronchodilator airflow obstruction (FEV1 62.2% predicted, FEV1/forced vital capacity 61.2%, forced expiratory flow between 25% and 75% exhalation 30.9% predicted), and frequent radiological bronchiectasis (40%), but had less psychophysiologic comorbidities. Allergic bronchopulmonary aspergillosis diagnosis was associated with higher treatment needs and stronger eosinophilic signals. Factors independently associated with A fumigatus sensitization in difficult asthma included maintenance oral corticosteroid use (odds ratio [OR], 3.34) and maximum log10 total IgE+1 (OR, 4.30), whereas for allergic bronchopulmonary aspergillosis included maintenance oral corticosteroid use (OR, 6.98), maximum log10 total IgE+1 (OR, 4.65), and radiological bronchiectasis (OR, 4.08). CONCLUSIONS A fumigatus sensitization in difficult asthma identifies a more severe form of airways disease associated with greater morbidity, treatment need, and airways dysfunction/damage, but fewer psychophysiologic comorbidities. Screening of A fumigatus status should be an early element in the comprehensive assessment of patients with difficult asthma.
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Affiliation(s)
- Heena Mistry
- Clinical and Experimental Sciences Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Asthma, Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; La Jolla Institute of Immunology, La Jolla, Calif; The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, United Kingdom
| | | | - Mohammad Aref Kyyaly
- Clinical and Experimental Sciences Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, United Kingdom
| | - Adnan Azim
- Clinical and Experimental Sciences Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Asthma, Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Clair Barber
- Clinical and Experimental Sciences Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Deborah Knight
- National Institute for Health Research Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Colin Newell
- National Institute for Health Research Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Hans Michael Haitchi
- Clinical and Experimental Sciences Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Asthma, Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Tom Wilkinson
- Clinical and Experimental Sciences Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Peter Howarth
- Clinical and Experimental Sciences Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | | | - Pandurangan Vijayanand
- Clinical and Experimental Sciences Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; La Jolla Institute of Immunology, La Jolla, Calif
| | - S Hasan Arshad
- Clinical and Experimental Sciences Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Asthma, Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, United Kingdom; Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Ramesh J Kurukulaaratchy
- Clinical and Experimental Sciences Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Asthma, Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, United Kingdom.
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27
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Wilkinson T, Soule S, Doogue M. Syndrome of inappropriate anti-diuretic hormone secondary to transient global amnesia. Intern Med J 2021; 51:1186-1187. [PMID: 34278683 DOI: 10.1111/imj.15410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/26/2020] [Accepted: 11/02/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Tom Wilkinson
- Canterbury District Health Board, Christchurch, New Zealand
| | - Steven Soule
- Canterbury District Health Board, Christchurch, New Zealand.,Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Matt Doogue
- Canterbury District Health Board, Christchurch, New Zealand.,Department of Medicine, University of Otago, Christchurch, New Zealand
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28
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Vancheeswaran R, Willcox ML, Stuart B, Knight M, Kandil H, Barlow A, Patel MH, Stockham J, O'Neill A, Clark TW, Wilkinson T, Little P, Francis N, Griffiths G, Moore M. Accuracy of rapid point-of-care antibody test in patients with suspected or confirmed COVID-19. J Infect 2021; 84:94-118. [PMID: 34273411 PMCID: PMC8278837 DOI: 10.1016/j.jinf.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/06/2021] [Accepted: 07/11/2021] [Indexed: 12/30/2022]
Affiliation(s)
- Rama Vancheeswaran
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford WD18 0HB
| | | | - Beth Stuart
- University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Matthew Knight
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford WD18 0HB
| | - Hala Kandil
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford WD18 0HB
| | - Andrew Barlow
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford WD18 0HB
| | - Mayon Haresh Patel
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford WD18 0HB
| | - Jade Stockham
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford WD18 0HB
| | - Aisling O'Neill
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford WD18 0HB
| | - Tristan W Clark
- University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Tom Wilkinson
- University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Paul Little
- University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Nick Francis
- University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Gareth Griffiths
- University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Michael Moore
- University of Southampton Faculty of Medicine, Southampton, United Kingdom
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29
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Watson A, Öberg L, Angermann B, Spalluto CM, Hühn M, Burke H, Cellura D, Freeman A, Muthas D, Etal D, Belfield G, Karlsson F, Nordström K, Ostridge K, Staples KJ, Wilkinson T. Dysregulation of COVID-19 related gene expression in the COPD lung. Respir Res 2021; 22:164. [PMID: 34051791 PMCID: PMC8164067 DOI: 10.1186/s12931-021-01755-3] [Citation(s) in RCA: 12] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/17/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) patients are at increased risk of poor outcome from Coronavirus disease (COVID-19). Early data suggest elevated Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) receptor angiotensin converting enzyme 2 (ACE2) expression, but relationships to disease phenotype and downstream regulators of inflammation in the Renin-Angiotensin system (RAS) are unknown. We aimed to determine the relationship between RAS gene expression relevant to SARS-CoV-2 infection in the lung with disease characteristics in COPD, and the regulation of newly identified SARS-CoV-2 receptors and spike-cleaving proteases, important for SARS-CoV-2 infection. METHODS We quantified gene expression using RNA sequencing of epithelial brushings and bronchial biopsies from 31 COPD and 37 control subjects. RESULTS ACE2 gene expression (log2-fold change (FC)) was increased in COPD compared to ex-smoking (HV-ES) controls in epithelial brushings (0.25, p = 0.042) and bronchial biopsies (0.23, p = 0.050), and correlated with worse lung function (r = - 0.28, p = 0.0090). ACE2 was further increased in frequent exacerbators compared to infrequent exacerbators (0.51, p = 0.00045) and associated with use of ACE inhibitors (ACEi) (0.50, p = 0.0034), having cardiovascular disease (0.23, p = 0.048) or hypertension (0.34, p = 0.0089), and inhaled corticosteroid use in COPD subjects in bronchial biopsies (0.33, p = 0.049). Angiotensin II receptor type (AGTR)1 and 2 expression was decreased in COPD bronchial biopsies compared to HV-ES controls with log2FC of -0.26 (p = 0.033) and - 0.40, (p = 0.0010), respectively. However, the AGTR1:2 ratio was increased in COPD subjects compared with HV-ES controls, log2FC of 0.57 (p = 0.0051). Basigin, a newly identified potential SARS-CoV-2 receptor was also upregulated in both brushes, log2FC of 0.17 (p = 0.0040), and bronchial biopsies, (log2FC of 0.18 (p = 0.017), in COPD vs HV-ES. Transmembrane protease, serine (TMPRSS)2 was not differentially regulated between control and COPD. However, various other spike-cleaving proteases were, including TMPRSS4 and Cathepsin B, in both epithelial brushes (log2FC of 0.25 (p = 0.0012) and log2FC of 0.56 (p = 5.49E-06), respectively) and bronchial biopsies (log2FC of 0.49 (p = 0.00021) and log2FC of 0.246 (p = 0.028), respectively). CONCLUSION This study identifies key differences in expression of genes related to susceptibility and aetiology of COVID-19 within the COPD lung. Further studies to understand the impact on clinical course of disease are now required.
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MESH Headings
- Aged
- Angiotensin-Converting Enzyme 2/genetics
- Angiotensin-Converting Enzyme 2/metabolism
- Basigin/genetics
- Basigin/metabolism
- COVID-19/diagnosis
- COVID-19/genetics
- COVID-19/metabolism
- COVID-19/physiopathology
- Case-Control Studies
- Female
- Forced Expiratory Volume
- Gene Expression Regulation
- Humans
- Lung/metabolism
- Lung/physiopathology
- Male
- Middle Aged
- Prognosis
- Pulmonary Disease, Chronic Obstructive/diagnosis
- Pulmonary Disease, Chronic Obstructive/genetics
- Pulmonary Disease, Chronic Obstructive/metabolism
- Pulmonary Disease, Chronic Obstructive/physiopathology
- Receptor, Angiotensin, Type 1/genetics
- Receptor, Angiotensin, Type 1/metabolism
- Receptor, Angiotensin, Type 2/genetics
- Receptor, Angiotensin, Type 2/metabolism
- Transcriptome
- Vital Capacity
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Affiliation(s)
- Alastair Watson
- Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Lisa Öberg
- Translational Science and Experimental Medicine, Research and Early Development, AstraZeneca, Respiratory & Immunology, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Bastian Angermann
- Translational Science and Experimental Medicine, Research and Early Development, AstraZeneca, Respiratory & Immunology, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - C Mirella Spalluto
- Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Michael Hühn
- Translational Science and Experimental Medicine, Research and Early Development, AstraZeneca, Respiratory & Immunology, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Hannah Burke
- Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Doriana Cellura
- Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Anna Freeman
- Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Daniel Muthas
- Translational Science and Experimental Medicine, Research and Early Development, AstraZeneca, Respiratory & Immunology, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Damla Etal
- Translational Genomics, Discovery Biology, Discovery Sciences, AstraZeneca, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Graham Belfield
- Translational Genomics, Discovery Biology, Discovery Sciences, AstraZeneca, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Fredrik Karlsson
- Data Sciences and Quantitative Biology, Discovery Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Karl Nordström
- Data Sciences and Quantitative Biology, Discovery Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Kris Ostridge
- Faculty of Medicine, University of Southampton, Southampton, UK
- Translational Science and Experimental Medicine, Research and Early Development, AstraZeneca, Respiratory & Immunology, BioPharmaceuticals R&D, Gothenburg, Sweden
- Clinical Development, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Karl J Staples
- Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Tom Wilkinson
- Faculty of Medicine, University of Southampton, Southampton, UK.
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK.
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30
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Geifman N, Azadbakht N, Zeng J, Wilkinson T, Dand N, Buchan I, Stocken D, Di Meglio P, Warren RB, Barker JN, Reynolds NJ, Barnes MR, Smith CH, Griffiths CEM, Peek N. Defining trajectories of response in patients with psoriasis treated with biologic therapies. Br J Dermatol 2021; 185:825-835. [PMID: 33829489 DOI: 10.1111/bjd.20140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The effectiveness and cost-effectiveness of biologic therapies for psoriasis are significantly compromised by variable treatment responses. Thus, more precise management of psoriasis is needed. OBJECTIVES To identify subgroups of patients with psoriasis treated with biologic therapies, based on changes in their disease activity over time, that may better inform patient management. METHODS We applied latent class mixed modelling to identify trajectory-based patient subgroups from longitudinal, routine clinical data on disease severity, as measured by the Psoriasis Area and Severity Index (PASI), from 3546 patients in the British Association of Dermatologists Biologics and Immunomodulators Register, as well as in an independent cohort of 2889 patients pooled across four clinical trials. RESULTS We discovered four discrete classes of global response trajectories, each characterized in terms of time to response, size of effect and relapse. Each class was associated with differing clinical characteristics, e.g. body mass index, baseline PASI and prevalence of different manifestations. The results were verified in a second cohort of clinical trial participants, where similar trajectories following the initiation of biologic therapy were identified. Further, we found differential associations of the genetic marker HLA-C*06:02 between our registry-identified trajectories. CONCLUSIONS These subgroups, defined by change in disease over time, may be indicative of distinct endotypes driven by different biological mechanisms and may help inform the management of patients with psoriasis. Future work will aim to further delineate these mechanisms by extensively characterizing the subgroups with additional molecular and pharmacological data.
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Affiliation(s)
- N Geifman
- The Manchester Molecular Pathology Innovation Centre, University of Manchester, Manchester, UK.,Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - N Azadbakht
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - J Zeng
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - T Wilkinson
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - N Dand
- School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Health Data Research UK, London, UK
| | - I Buchan
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - D Stocken
- Clinical Trials Research Unit, University of Leeds, UK
| | - P Di Meglio
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - R B Warren
- Dermatology Centre, Salford Royal NHS Foundation Trust, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
| | - J N Barker
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - N J Reynolds
- Institute of Translational and Clinical Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK.,Department of Dermatology, Royal Victoria Infirmary, and NIHR Newcastle Biomedical Research Centre, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M R Barnes
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - C H Smith
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - C E M Griffiths
- Dermatology Centre, Salford Royal NHS Foundation Trust, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
| | - N Peek
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
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31
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Urion RJ, Edwards RB, Mattoon JS, Wilkinson T. What Is Your Diagnosis? J Am Vet Med Assoc 2021; 258:257-259. [PMID: 33496622 DOI: 10.2460/javma.258.3.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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32
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Tree JA, Turnbull JE, Buttigieg KR, Elmore MJ, Coombes N, Hogwood J, Mycroft-West CJ, Lima MA, Skidmore MA, Karlsson R, Chen YH, Yang Z, Spalluto CM, Staples KJ, Yates EA, Gray E, Singh D, Wilkinson T, Page CP, Carroll MW. Unfractionated heparin inhibits live wild type SARS-CoV-2 cell infectivity at therapeutically relevant concentrations. Br J Pharmacol 2021. [PMID: 33125711 DOI: 10.1111/bph.v178.310.1111/bph.15304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND AND PURPOSE Currently, there are no licensed vaccines and limited antivirals for the treatment of COVID-19. Heparin (delivered systemically) is currently used to treat anticoagulant anomalies in COVID-19 patients. Additionally, in the United Kingdom, Brazil and Australia, nebulised unfractionated heparin (UFH) is being trialled in COVID-19 patients as a potential treatment. A systematic comparison of the potential antiviral effect of various heparin preparations on live wild type SARS-CoV-2, in vitro, is needed. EXPERIMENTAL APPROACH Seven different heparin preparations including UFH and low MW heparins (LMWH) of porcine or bovine origin were screened for antiviral activity against live SARS-CoV-2 (Australia/VIC01/2020) using a plaque inhibition assay with Vero E6 cells. Interaction of heparin with spike protein RBD was studied using differential scanning fluorimetry and the inhibition of RBD binding to human ACE2 protein using elisa assays was examined. KEY RESULTS All the UFH preparations had potent antiviral effects, with IC50 values ranging between 25 and 41 μg·ml-1 , whereas LMWHs were less inhibitory by ~150-fold (IC50 range 3.4-7.8 mg·ml-1 ). Mechanistically, we observed that heparin binds and destabilizes the RBD protein and furthermore, we show heparin directly inhibits the binding of RBD to the human ACE2 protein receptor. CONCLUSION AND IMPLICATIONS This comparison of clinically relevant heparins shows that UFH has significantly stronger SARS-CoV-2 antiviral activity compared to LMWHs. UFH acts to directly inhibit binding of spike protein to the human ACE2 protein receptor. Overall, the data strongly support further clinical investigation of UFH as a potential treatment for patients with COVID-19.
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Affiliation(s)
- Julia A Tree
- National Infection Service, Public Health England, Porton Down, Salisbury, UK
| | - Jeremy E Turnbull
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular & Integrative Biology, University of Liverpool, Liverpool, UK
- Copenhagen Center for Glycomics, Department of Cellular & Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Karen R Buttigieg
- National Infection Service, Public Health England, Porton Down, Salisbury, UK
| | - Michael J Elmore
- National Infection Service, Public Health England, Porton Down, Salisbury, UK
| | - Naomi Coombes
- National Infection Service, Public Health England, Porton Down, Salisbury, UK
| | - John Hogwood
- Haemostasis Section, Biotherapeutics, National Institute for Biological Standards and Control (NIBSC), Potters Bar, UK
| | - Courtney J Mycroft-West
- Molecular & Structural Biosciences, School of Life Sciences, Keele University, Newcastle-Under-Lyme, UK
| | - Marcelo A Lima
- Molecular & Structural Biosciences, School of Life Sciences, Keele University, Newcastle-Under-Lyme, UK
| | - Mark A Skidmore
- Molecular & Structural Biosciences, School of Life Sciences, Keele University, Newcastle-Under-Lyme, UK
| | - Richard Karlsson
- Copenhagen Center for Glycomics, Department of Cellular & Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Yen-Hsi Chen
- Copenhagen Center for Glycomics, Department of Cellular & Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Zhang Yang
- Copenhagen Center for Glycomics, Department of Cellular & Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Karl J Staples
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Edwin A Yates
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular & Integrative Biology, University of Liverpool, Liverpool, UK
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics, National Institute for Biological Standards and Control (NIBSC), Potters Bar, UK
- Sackler Institute of Pulmonary Pharmacology, King's College London, London, UK
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Tom Wilkinson
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, London, UK
| | - Miles W Carroll
- National Infection Service, Public Health England, Porton Down, Salisbury, UK
- Nuffield Department of Medicine, Wellcome Trust Centre for Human Genetics, Oxford University, Oxford, UK
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Burke H, Freeman A, Dushianthan A, Celinski M, Batchelor J, Phan H, Borca F, Kipps C, Thomas GJ, Faust SN, Sheard N, Williams S, Fitzpatrick P, Landers D, Wilkinson T. Research Evaluation Alongside Clinical Treatment in COVID-19 (REACT COVID-19): an observational and biobanking study. BMJ Open 2021; 11:e043012. [PMID: 33483446 PMCID: PMC7830323 DOI: 10.1136/bmjopen-2020-043012] [Citation(s) in RCA: 8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic caused by SARS-CoV-2 places immense worldwide demand on healthcare services. Earlier identification of patients at risk of severe disease may allow intervention with experimental targeted treatments, mitigating the course of their disease and reducing critical care service demand. METHODS AND ANALYSIS This prospective observational study of patients tested or treated for SARS-CoV-2, who are under the care of the tertiary University Hospital Southampton NHS Foundation Trust (UHSFT), captured data from admission to discharge; data collection commenced on 7 March 2020. Core demographic and clinical information, as well as results of disease-defining characteristics, was captured and recorded electronically from hospital clinical record systems at the point of testing. Manual data were collected and recorded by the clinical research team for assessments which are not part of the structured electronic healthcare record, for example, symptom onset date. Thereafter, participant records were continuously updated during hospital stay and their follow-up period. Participants aged >16 years were given the opportunity to provide consent for excess clinical sample storage with optional further biological sampling. These anonymised samples were linked to the clinical data in the Real-time Analytics for Clinical Trials platform and were stored within a biorepository at UHSFT. ETHICS AND DISSEMINATION Ethical approval was obtained from the HRA Specific Review Board (REC 20/HRA/2986) for waiver of informed consent for the database-only cohort; the procedures conform with the Declaration of Helsinki. The study design, protocol and patient-facing documentation for the biobanking arm of the study have been approved by North West Research Ethics Committee (REC 17/NW/0632) as an amendment to the National Institute for Health Research Southampton Clinical Research Facility-managed Southampton Research Biorepository. This study will be published as peer-reviewed articles and presented at conferences, presentations and workshops.
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Affiliation(s)
- Hannah Burke
- Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - Anna Freeman
- Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - Ahilanandan Dushianthan
- Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - Michael Celinski
- Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - James Batchelor
- Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
- Institute for Life Sciences, University of Southampton, Southampton, UK
- Clinical Informatics Research Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Hang Phan
- Faculty of Medicine, University of Southampton, Southampton, UK
- Clinical Informatics Research Unit, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Florina Borca
- Institute for Life Sciences, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Christopher Kipps
- Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
- Institute for Life Sciences, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gareth J Thomas
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, UK
| | - Saul N Faust
- Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
- Institute for Life Sciences, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Natasha Sheard
- University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - Sarah Williams
- University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - Paul Fitzpatrick
- University of Manchester, Cancer Biomarker Centre, Cancer Research UK Manchester Institute, Manchester, UK
| | - Dónal Landers
- University of Manchester, Cancer Biomarker Centre, Cancer Research UK Manchester Institute, Manchester, UK
| | - Tom Wilkinson
- Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
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Cleary SM, Wilkinson T, Tamandjou Tchuem CR, Docrat S, Solanki GC. Cost-effectiveness of intensive care for hospitalized COVID-19 patients: experience from South Africa. BMC Health Serv Res 2021; 21:82. [PMID: 33482807 PMCID: PMC7820836 DOI: 10.1186/s12913-021-06081-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [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] [Received: 11/17/2020] [Accepted: 01/12/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Given projected shortages of critical care capacity in public hospitals during the COVID-19 pandemic, the South African government embarked on an initiative to purchase this capacity from private hospitals. In order to inform purchasing decisions, we assessed the cost-effectiveness of intensive care management for admitted COVID-19 patients across the public and private health systems in South Africa. METHODS Using a modelling framework and health system perspective, costs and health outcomes of inpatient management of severe and critical COVID-19 patients in (1) general ward and intensive care (GW + ICU) versus (2) general ward only (GW) were assessed. Disability adjusted life years (DALYs) were evaluated and the cost per admission in public and private sectors was determined. The model made use of four variables: mortality rates, utilisation of inpatient days for each management approach, disability weights associated with severity of disease, and the unit cost per general ward day and per ICU day in public and private hospitals. Unit costs were multiplied by utilisation estimates to determine the cost per admission. DALYs were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). An incremental cost-effectiveness ratio (ICER) - representing difference in costs and health outcomes of the two management strategies - was compared to a cost-effectiveness threshold to determine the value for money of expansion in ICU services during COVID-19 surges. RESULTS A cost per admission of ZAR 75,127 was estimated for inpatient management of severe and critical COVID-19 patients in GW as opposed to ZAR 103,030 in GW + ICU. DALYs were 1.48 and 1.10 in GW versus GW + ICU, respectively. The ratio of difference in costs and health outcomes between the two management strategies produced an ICER of ZAR 73,091 per DALY averted, a value above the cost-effectiveness threshold of ZAR 38,465. CONCLUSIONS Results indicated that purchasing ICU capacity from the private sector during COVID-19 surges may not be a cost-effective investment. The 'real time', rapid, pragmatic, and transparent nature of this analysis demonstrates an approach for evidence generation for decision making relating to the COVID-19 pandemic response and South Africa's wider priority setting agenda.
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Affiliation(s)
- S M Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - T Wilkinson
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - C R Tamandjou Tchuem
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - S Docrat
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - G C Solanki
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,NMG Consultants and Actuaries, Cape Town, South Africa
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van Haren FMP, Richardson A, Yoon HJ, Artigas A, Laffey JG, Dixon B, Smith R, Vilaseca AB, Barbera RA, Ismail TI, Mahrous RS, Badr M, De Nucci G, Sverdloff C, van Loon LM, Camprubi-Rimblas M, Cosgrave DW, Smoot TL, Staas S, Sann K, Sas C, Belani A, Hillman C, Shute J, Carroll M, Wilkinson T, Carroll M, Singh D, Page C. INHALEd nebulised unfractionated HEParin for the treatment of hospitalised patients with COVID-19 (INHALE-HEP): Protocol and statistical analysis plan for an investigator-initiated international metatrial of randomised studies. Br J Clin Pharmacol 2021; 87:3075-3091. [PMID: 33377218 DOI: 10.1111/bcp.14714] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 02/07/2023] Open
Abstract
AIMS Inhaled nebulised unfractionated heparin (UFH) has a strong scientific and biological rationale that warrants urgent investigation of its therapeutic potential in patients with COVID-19. UFH has antiviral effects and prevents the SARS-CoV-2 virus' entry into mammalian cells. In addition, UFH has significant anti-inflammatory and anticoagulant properties, which limit progression of lung injury and vascular pulmonary thrombosis. METHODS The INHALEd nebulised unfractionated HEParin for the treatment of hospitalised patients with COVID-19 (INHALE-HEP) metatrial is a prospective individual patient data analysis of on-going randomised controlled trials and early phase studies. Individual studies are being conducted in multiple countries. Participating studies randomise adult patients admitted to the hospital with confirmed SARS-CoV-2 infection, who do not require immediate mechanical ventilation, to inhaled nebulised UFH or standard care. All studies collect a minimum core dataset. The primary outcome for the metatrial is intubation (or death, for patients who died before intubation) at day 28. The secondary outcomes are oxygenation, clinical worsening and mortality, assessed in time-to-event analyses. Individual studies may have additional outcomes. ANALYSIS We use a Bayesian approach to monitoring, followed by analysing individual patient data, outcomes and adverse events. All analyses will follow the intention-to-treat principle, considering all participants in the treatment group to which they were assigned, except for cases lost to follow-up or withdrawn. TRIAL REGISTRATION, ETHICS AND DISSEMINATION The metatrial is registered at ClinicalTrials.gov ID NCT04635241. Each contributing study is individually registered and has received approval of the relevant ethics committee or institutional review board. Results of this study will be shared with the World Health Organisation, published in scientific journals and presented at scientific meetings.
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Affiliation(s)
- Frank M P van Haren
- Australian National University, College of Health and Medicine, Canberra, Australia.,Faculty of Health, University of Canberra, Canberra, Australia
| | - Alice Richardson
- Statistical Consulting Unit, Australian National University, Canberra, Australia
| | - Hwan-Jin Yoon
- Statistical Consulting Unit, Australian National University, Canberra, Australia
| | - Antonio Artigas
- Critical Center, Corporació Universitaria Sanitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland.,Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Ireland
| | - Barry Dixon
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Roger Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Alicia B Vilaseca
- Service of Haematology and Haemostasis, San Camilo Clinic, Buenos Aires, Argentina
| | - Ruben A Barbera
- Service of Haematology and Haemostasis, San Camilo Clinic, Buenos Aires, Argentina
| | - Tarek I Ismail
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Rabab S Mahrous
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mohamed Badr
- Department of Critical Care Medicine, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Gilberto De Nucci
- Department of Pharmacology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil.,Department of Pharmacology, Institute of Biomedical Sciences, University of São Paulo, Brazil
| | - Carlos Sverdloff
- Department of Pharmacology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Lex M van Loon
- Australian National University, College of Health and Medicine, Canberra, Australia
| | - Marta Camprubi-Rimblas
- Critical Center, Corporació Universitaria Sanitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain
| | - David W Cosgrave
- Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Ireland
| | | | - Sabrina Staas
- Frederick Memorial Hospital, Frederick, Maryland, USA
| | - Khine Sann
- Frederick Memorial Hospital, Frederick, Maryland, USA
| | - Caitlin Sas
- Frederick Memorial Hospital, Frederick, Maryland, USA
| | - Anusha Belani
- Frederick Memorial Hospital, Frederick, Maryland, USA
| | | | - Janis Shute
- School of Pharmacy and Biomedical Science, University of Portsmouth, Portsmouth, UK
| | - Mary Carroll
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Tom Wilkinson
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Miles Carroll
- National Infection Service, Public Health England, Porton Down, UK
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester, UK
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, UK
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36
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Tree JA, Turnbull JE, Buttigieg KR, Elmore MJ, Coombes N, Hogwood J, Mycroft-West CJ, Lima MA, Skidmore MA, Karlsson R, Chen YH, Yang Z, Spalluto CM, Staples KJ, Yates EA, Gray E, Singh D, Wilkinson T, Page CP, Carroll MW. Unfractionated heparin inhibits live wild type SARS-CoV-2 cell infectivity at therapeutically relevant concentrations. Br J Pharmacol 2020; 178:626-635. [PMID: 33125711 PMCID: PMC9328389 DOI: 10.1111/bph.15304] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [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] [Received: 07/13/2020] [Revised: 10/08/2020] [Accepted: 10/18/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE Currently, there are no licensed vaccines and limited antivirals for the treatment of COVID-19. Heparin (delivered systemically) is currently used to treat anticoagulant anomalies in COVID-19 patients. Additionally, in the United Kingdom, Brazil and Australia, nebulised unfractionated heparin (UFH) is being trialled in COVID-19 patients as a potential treatment. A systematic comparison of the potential antiviral effect of various heparin preparations on live wild type SARS-CoV-2, in vitro, is needed. EXPERIMENTAL APPROACH Seven different heparin preparations including UFH and low MW heparins (LMWH) of porcine or bovine origin were screened for antiviral activity against live SARS-CoV-2 (Australia/VIC01/2020) using a plaque inhibition assay with Vero E6 cells. Interaction of heparin with spike protein RBD was studied using differential scanning fluorimetry and the inhibition of RBD binding to human ACE2 protein using elisa assays was examined. KEY RESULTS All the UFH preparations had potent antiviral effects, with IC50 values ranging between 25 and 41 μg·ml-1 , whereas LMWHs were less inhibitory by ~150-fold (IC50 range 3.4-7.8 mg·ml-1 ). Mechanistically, we observed that heparin binds and destabilizes the RBD protein and furthermore, we show heparin directly inhibits the binding of RBD to the human ACE2 protein receptor. CONCLUSION AND IMPLICATIONS This comparison of clinically relevant heparins shows that UFH has significantly stronger SARS-CoV-2 antiviral activity compared to LMWHs. UFH acts to directly inhibit binding of spike protein to the human ACE2 protein receptor. Overall, the data strongly support further clinical investigation of UFH as a potential treatment for patients with COVID-19.
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Affiliation(s)
- Julia A Tree
- National Infection Service, Public Health England, Porton Down, Salisbury, UK
| | - Jeremy E Turnbull
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular & Integrative Biology, University of Liverpool, Liverpool, UK.,Copenhagen Center for Glycomics, Department of Cellular & Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Karen R Buttigieg
- National Infection Service, Public Health England, Porton Down, Salisbury, UK
| | - Michael J Elmore
- National Infection Service, Public Health England, Porton Down, Salisbury, UK
| | - Naomi Coombes
- National Infection Service, Public Health England, Porton Down, Salisbury, UK
| | - John Hogwood
- Haemostasis Section, Biotherapeutics, National Institute for Biological Standards and Control (NIBSC), Potters Bar, UK
| | - Courtney J Mycroft-West
- Molecular & Structural Biosciences, School of Life Sciences, Keele University, Newcastle-Under-Lyme, UK
| | - Marcelo A Lima
- Molecular & Structural Biosciences, School of Life Sciences, Keele University, Newcastle-Under-Lyme, UK
| | - Mark A Skidmore
- Molecular & Structural Biosciences, School of Life Sciences, Keele University, Newcastle-Under-Lyme, UK
| | - Richard Karlsson
- Copenhagen Center for Glycomics, Department of Cellular & Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Yen-Hsi Chen
- Copenhagen Center for Glycomics, Department of Cellular & Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Zhang Yang
- Copenhagen Center for Glycomics, Department of Cellular & Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Karl J Staples
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Edwin A Yates
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular & Integrative Biology, University of Liverpool, Liverpool, UK
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics, National Institute for Biological Standards and Control (NIBSC), Potters Bar, UK.,Sackler Institute of Pulmonary Pharmacology, King's College London, London, UK
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Tom Wilkinson
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, London, UK
| | - Miles W Carroll
- National Infection Service, Public Health England, Porton Down, Salisbury, UK.,Nuffield Department of Medicine, Wellcome Trust Centre for Human Genetics, Oxford University, Oxford, UK
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Day K, Ostridge K, Conway J, Cellura D, Watson A, Spalluto CM, Staples KJ, Thompson B, Wilkinson T. Interrelationships Among Small Airways Dysfunction, Neutrophilic Inflammation, and Exacerbation Frequency in COPD. Chest 2020; 159:1391-1399. [PMID: 33245876 DOI: 10.1016/j.chest.2020.11.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 03/19/2020] [Revised: 11/03/2020] [Accepted: 11/08/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Small airways disease (SAD) is a key component of COPD and is a main contributing factor to lung function decline. RESEARCH QUESTION Is SAD a key feature of frequent COPD exacerbators and is this related to airway inflammation? STUDY DESIGN AND METHODS Thirty-nine COPD patients defined as either frequent exacerbator (FE) group (≥ 2 exacerbations/y; n = 17) and infrequent exacerbator (IFE) group (≤ 1 exacerbation/y; n = 22) underwent the forced oscillation technique (resistance at 5 Hz minus 19 Hz [R5-R19], area of reactance [AX]), multiple breath nitrogen washout (conducting airways ventilation heterogeneity, acinar ventilation heterogeneity [Sacin]), plethysmography (ratio of residual volume to total lung capacity), single-breath transfer factor of the lung for carbon monoxide, spirometry (FEV1, FEV1/FVC), and paired inspiratory-expiratory CT scans to ascertain SAD. A subpopulation underwent bronchoscopy to enable enumeration of BAL cell proportions. RESULTS Sacin was significantly higher in the COPD FE group compared with the IFE group (P = .027). In the FE group, markers of SAD were associated strongly with BAL neutrophil proportions, R5-R19 (P = .001, r = 0.795), AX (P = .049, ρ = 0.560), residual volume to total lung capacity ratio (P = .004, r = 0.730), and the mean lung density of the paired CT scans (P = .018, r = 0.639). INTERPRETATION Increased Sacin may be a consequence of previous exacerbations or may highlight a group of patients prone to exacerbations. Measures of SAD were associated strongly with neutrophilic inflammation in the small airways of FE patients, supporting the hypothesis that frequent exacerbations are associated with SAD related to increased cellular inflammation.
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Affiliation(s)
- Kerry Day
- Faculty of Medicine, University of Southampton, Southampton; NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton.
| | - Kristoffer Ostridge
- Faculty of Medicine, University of Southampton, Southampton; NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton; Clinical Development, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | | | | | | | - Karl J Staples
- Faculty of Medicine, University of Southampton, Southampton; NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton
| | - Bruce Thompson
- Swinburne University of Technology, Melbourne, Australia
| | - Tom Wilkinson
- Faculty of Medicine, University of Southampton, Southampton; NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton
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Rengert R, Wilkinson T, Singh A, Brisson BA, Fransson B. Morphology of the cisterna chyli in nine dogs with idiopathic chylothorax and in six healthy dogs assessed by computed tomographic lymphangiography. Vet Surg 2020; 50:223-229. [PMID: 33175400 DOI: 10.1111/vsu.13538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/13/2020] [Accepted: 10/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the morphology of the lymphatics in the region of the cisterna chyli in healthy dogs and in dogs with idiopathic chylothorax by using computed tomographic lymphangiography. STUDY DESIGN Retrospective study. ANIMALS Nine dogs with idiopathic chylothorax and six healthy dogs. METHODS Computed tomographic lymphangiograms were reviewed to evaluate the number of cisterna chyli branches, total cross-sectional area of the branches normalized to the cross-sectional area of the aorta, number of branches with cross-sectional area greater than 25% of the aorta cross-sectional area, and ratio of the total perimeter to the total cross-sectional area of the branches. Data (mean ± SD) were compared between unaffected dogs and dogs with idiopathic chylothorax. RESULTS The cisterna chyli included more branches in dogs with chylothorax (4.30 ± 1.57) than in unaffected dogs (1.67 ± 0.56, P = .02), occupying a relative perimeter approximately double that in unaffected dogs (P < .001). The relative cross-sectional area of the cisterna chyli was approximately twofold smaller in affected (0.73 ± 0.35) than in unaffected (1.63 ± 0.91, P = .02) dogs. The fraction of dogs with branches greater than 25% of the cross-sectional area of the aorta tended to be larger in unaffected dogs (P = .07). Most larger branches were located dorsal or to the right of the aorta. CONCLUSION The cisterna chyli of dogs with idiopathic chylothorax contained smaller and more numerous branches compared with that of unaffected dogs. CLINICAL SIGNIFICANCE Altered cisterna chyli morphology may impact the surgical approach for cisterna chyli ablation in dogs with idiopathic chylothorax.
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Affiliation(s)
- Roger Rengert
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
| | - Tom Wilkinson
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
| | - Ameet Singh
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Brigitte A Brisson
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Boel Fransson
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
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Bartel S, Deshane J, Wilkinson T, Gabrielsson S. Extracellular Vesicles as Mediators of Cellular Cross Talk in the Lung Microenvironment. Front Med (Lausanne) 2020; 7:326. [PMID: 32850874 PMCID: PMC7417309 DOI: 10.3389/fmed.2020.00326] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/03/2020] [Indexed: 12/27/2022] Open
Abstract
The human lung is a complex tissue subdivided into several regions that differ in size, function, and resident cell types. Despite years of intensive research, we still do not fully understand the cross talk between these different regions and diverse cell populations in the lung and how this is altered in the development of chronic respiratory disease. The discovery of extracellular vesicles (EVs), small membrane vesicles released from cells for intercellular communication, has added another layer of complexity to cellular cross talk in the complex lung microenvironment. EVs from patients with chronic obstructive pulmonary disease, asthma, or sarcoidosis have been shown to carry microRNAs, proteins, and lipids that may contribute to inflammation or tissue degeneration. Here, we summarize the contribution of these small vesicles in the interplay of several different cell types in the lung microenvironment, with a focus on the development of chronic respiratory diseases. Although there are already many studies demonstrating the adverse effects of EVs in the diseased lung, we still have substantial knowledge gaps regarding the concrete role of EV involvement in lung disease, which should be addressed in future studies.
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Affiliation(s)
- Sabine Bartel
- Department of Pathology and Medical Biology, GRIAC Research Institute, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Jessy Deshane
- Pulmonary Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tom Wilkinson
- Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Susanne Gabrielsson
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden.,Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
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Wilkinson T, Dixon R, Page C, Carroll M, Griffiths G, Ho LP, De Soyza A, Felton T, Lewis KE, Phekoo K, Chalmers JD, Gordon A, McGarvey L, Doherty J, Read RC, Shankar-Hari M, Martinez-Alier N, O’Kelly M, Duncan G, Walles R, Sykes J, Summers C, Singh D. ACCORD: A Multicentre, Seamless, Phase 2 Adaptive Randomisation Platform Study to Assess the Efficacy and Safety of Multiple Candidate Agents for the Treatment of COVID-19 in Hospitalised Patients: A structured summary of a study protocol for a randomised controlled trial. Trials 2020; 21:691. [PMID: 32736596 PMCID: PMC7393340 DOI: 10.1186/s13063-020-04584-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [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: 07/01/2020] [Accepted: 07/04/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Stage 1: To evaluate the safety and efficacy of candidate agents as add-on therapies to standard of care (SoC) in patients hospitalised with COVID-19 in a screening stage. Stage 2: To confirm the efficacy of candidate agents selected on the basis of evidence from Stage 1 in patients hospitalised with COVID-19 in an expansion stage. TRIAL DESIGN ACCORD is a seamless, Phase 2, adaptive, randomised controlled platform study, designed to rapidly test candidate agents in the treatment of COVID-19. Designed as a master protocol with each candidate agent being included via its own sub-protocol, initially randomising equally between each candidate and a single contemporaneous SoC arm (which can adapt into 2:1). Candidate agents currently include bemcentinib, MEDI3506, acalabrutinib, zilucoplan and nebulised heparin. For each candidate a total of 60 patients will be recruited in Stage 1. If Stage 1 provides evidence of efficacy and acceptable safety the candidate will enter Stage 2 where a total of approximately 126 patients will be recruited into each study arm sub-protocol. Enrollees and outcomes will not be shared across the Stages; the endpoint, analysis and sample size for Stage 2 may be adjusted based on evidence from Stage 1. Additional arms may be added as new potential candidate agents are identified via candidate agent specific sub-protocols. PARTICIPANTS The study will include hospitalised adult patients (≥18 years) with confirmed SARS-CoV-2 infection, the virus that causes COVID-19, that clinically meet Grades 3 (hospitalised - mild disease, no oxygen therapy), Grades 4 (hospitalised, oxygen by mask or nasal prongs) and 5 (hospitalised, non-invasive ventilation or high flow oxygen) of the WHO Working Group on the Clinical Characteristics of COVID-19 9-point category ordinal scale. Participants will be recruited from England, Northern Ireland, Wales and Scotland. INTERVENTION AND COMPARATOR Comparator is current standard of care (SoC) for the treatment of COVID-19. Current candidate experimental arms include bemcentinib, MEDI3506, acalabrutinib, zilucoplan and nebulised heparin with others to be added over time. Bemcentinib could potentially reduce viral infection and blocks SARS-CoV-2 spike protein; MEDI3506 is a clinic-ready anti-IL-33 monoclonal antibody with the potential to treat respiratory failure caused by COVID; acalabrutinib is a BTK inhibitor which is anti-viral and anti-inflammatory; zilucoplan is a complement C5 inhibitor which may block the severe inflammatory response in COVID-19 and; nebulised heparin has been shown to bind with the spike protein. ACCORD is linked with the UK national COVID therapeutics task force to help prioritise candidate agents. MAIN OUTCOMES Time to sustained clinical improvement of at least 2 points (from randomisation) on the WHO 9-point category ordinal scale, live discharge from the hospital, or considered fit for discharge (a score of 0, 1, or 2 on the ordinal scale), whichever comes first, by Day 29 (this will also define the "responder" for the response rate analyses). RANDOMISATION An electronic randomization will be performed by Cenduit using Interactive Response Technology (IRT). Randomisation will be stratified by baseline severity grade. Randomisation will proceed with an equal allocation to each arm and a contemporaneous SoC arm (e.g. 1:1 if control and 1 experimental arm; 1:1:1 if two experimental candidate arms etc) but will be reviewed as the trial progresses and may be changed to 2:1 in favour of the candidate agents. BLINDING (MASKING) The trial is open label and no blinding is currently planned in the study. NUMBERS TO BE RANDOMISED (SAMPLE SIZE) This will be in the order of 60 patients per candidate agent for Stage 1, and 126 patients for Stage 2. However, sample size re-estimation may be considered after Stage 1. It is estimated that up to 1800 patients will participate in the overall study. TRIAL STATUS Master protocol version ACCORD-2-001 - Master Protocol (Amendment 1) 22nd April 2020, the trial has full regulatory approval and recruitment is ongoing in the bemcentinib (first patient recruited 6/5/2020), MEDI3506 (first patient recruited 19/5/2020), acalabrutinib (first patient recruited 20/5/2020) and zilucoplan (first patient recruited 19/5/2020) candidates (and SoC). The recruitment dates of each arm will vary between candidate agents as they are added or dropped from the trial, but will have recruited and reported within a year. TRIAL REGISTRATION EudraCT 2020-001736-95 , registered 28th April 2020. FULL PROTOCOL The full protocol (Master Protocol with each of the candidate sub-protocols) is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.
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Affiliation(s)
- Tom Wilkinson
- University of Southampton, Southampton, Hampshire UK
- NIHR Southampton Biomedical Research Centre, Southampton, UK
| | | | | | | | | | - Ling-Pei Ho
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Anthony De Soyza
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Timothy Felton
- Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
| | | | - Karen Phekoo
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | | | - Jillian Doherty
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Robert C. Read
- University of Southampton, Southampton, Hampshire UK
- NIHR Southampton Biomedical Research Centre, Southampton, UK
| | | | - Nuria Martinez-Alier
- IQVIA, Reading, UK
- Evelina London Children’s Hospital Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | | | - Dave Singh
- University of Manchester, Manchester, UK
| | - on behalf of the ACCORD Collaborators
- University of Southampton, Southampton, Hampshire UK
- NIHR Southampton Biomedical Research Centre, Southampton, UK
- IQVIA, Reading, UK
- King’s College London, London, UK
- Public Health England, London, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
- Swansea University, Swansea, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University of Dundee, Dundee, UK
- Imperial College London, London, UK
- Queen’s University Belfast, Belfast, UK
- Evelina London Children’s Hospital Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
- IQVIA, Dublin, Ireland
- IQVIA, Edinburgh, UK
- University of Cambridge, Cambridge, UK
- University of Manchester, Manchester, UK
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van Haren FMP, Page C, Laffey JG, Artigas A, Camprubi-Rimblas M, Nunes Q, Smith R, Shute J, Carroll M, Tree J, Carroll M, Singh D, Wilkinson T, Dixon B. Nebulised heparin as a treatment for COVID-19: scientific rationale and a call for randomised evidence. Crit Care 2020; 24:454. [PMID: 32698853 PMCID: PMC7374660 DOI: 10.1186/s13054-020-03148-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/03/2020] [Indexed: 12/16/2022] Open
Abstract
Nebulised unfractionated heparin (UFH) has a strong scientific and biological rationale and warrants urgent investigation of its therapeutic potential, for COVID-19-induced acute respiratory distress syndrome (ARDS). COVID-19 ARDS displays the typical features of diffuse alveolar damage with extensive pulmonary coagulation activation resulting in fibrin deposition in the microvasculature and formation of hyaline membranes in the air sacs. Patients infected with SARS-CoV-2 who manifest severe disease have high levels of inflammatory cytokines in plasma and bronchoalveolar lavage fluid and significant coagulopathy. There is a strong association between the extent of the coagulopathy and poor clinical outcomes.The anti-coagulant actions of nebulised UFH limit fibrin deposition and microvascular thrombosis. Trials in patients with acute lung injury and related conditions found inhaled UFH reduced pulmonary dead space, coagulation activation, microvascular thrombosis and clinical deterioration, resulting in increased time free of ventilatory support. In addition, UFH has anti-inflammatory, mucolytic and anti-viral properties and, specifically, has been shown to inactivate the SARS-CoV-2 virus and prevent its entry into mammalian cells, thereby inhibiting pulmonary infection by SARS-CoV-2. Furthermore, clinical studies have shown that inhaled UFH safely improves outcomes in other inflammatory respiratory diseases and also acts as an effective mucolytic in sputum-producing respiratory patients. UFH is widely available and inexpensive, which may make this treatment also accessible for low- and middle-income countries.These potentially important therapeutic properties of nebulised UFH underline the need for expedited large-scale clinical trials to test its potential to reduce mortality in COVID-19 patients.
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Affiliation(s)
- Frank M P van Haren
- Australian National University, Medical School, Canberra, Australia.
- Intensive Care Unit, the Canberra Hospital, Canberra, Australia.
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, London, UK
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland
- Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Antonio Artigas
- Critical Center, Corporació Sanitaria Parc Tauli , CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain
| | - Marta Camprubi-Rimblas
- Institut d'Investigació I Innovació Parc Tauli (I3PT), CIBER de Enfermedades Respiratorias, Sabadell, Spain
| | - Quentin Nunes
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Roger Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Janis Shute
- School of Pharmacy and Biomedical Science, University of Portsmouth, Portsmouth, UK
| | - Mary Carroll
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Julia Tree
- National Infection Service, Public Health England, Porton Down, UK
| | - Miles Carroll
- National Infection Service, Public Health England, Porton Down, UK
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester, UK
| | - Tom Wilkinson
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Barry Dixon
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
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Crossley D, Stockley J, Bolton CE, Hopkinson NS, Mahadeva R, Steiner M, Wilkinson T, Hurst JR, Gooptu B, Stockley RA. Relationship of CT densitometry to lung physiological parameters and health status in alpha-1 antitrypsin deficiency: initial report of a centralised database of the NIHR rare diseases translational research collaborative. BMJ Open 2020; 10:e036045. [PMID: 32606060 PMCID: PMC7328802 DOI: 10.1136/bmjopen-2019-036045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES To establish a database network for the study of alpha-1 antitrypsin deficiency (AATD) and compare the results to CT lung density as the most direct measure of emphysema. DESIGN A central electronic database was established to permit the upload of anonymised patient data from remote sites. Prospectively collected CT data were recorded onto disc, anonymised, analysed at the coordinating centre and compared with the clinical features of the disease. SETTING Tertiary referral centres with expertise in the management of AATD focused on academic Biomedical Research Units and Wellcome Clinical Research Facilities. PARTICIPANTS Data were collected from 187 patients over 1 year from eight UK academic sites. This included patient demographics, postbronchodilator physiology, health status and CT. Analysis was undertaken at the coordinating centre in Birmingham. RESULTS Patient recruitment in the 12 months reached 94% of target (set at 200) covering the whole spectrum of the disease from those with normal lung function to very severe chronic obstructive lung disease. CT scan suitable for analysis was available from 147 (79%) of the patients. CT density, analysed as the threshold for the lowest 15% of lung voxels, showed statistically significant relationships with the objective physiological parameters of lung function as determined by spirometric Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity staging (p<0.001) and carbon monoxide gas transfer (p<0.01). Density also correlated with subjective measures of quality of life (p=0.02). CONCLUSIONS Establishment of the network for data collection and its transfer was highly successful facilitating future collaboration for the study of this rare disease and its management. CT densitometry correlated well with the objective clinical features of the disease supporting its role as the specific marker of the associated emphysema and its severity. Correlations with subjective measures of health, however, were generally weak indicating other factors play a role.
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Affiliation(s)
- Diana Crossley
- College of Medical and Dental Sciences, Institute of Inflammation and Ageing, Centre for Translational Inflammation Research, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK
| | - James Stockley
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, UK
| | - Charlotte E Bolton
- Department of Respiratory Medicine, NIHR Nottingham BRC respiratory theme, School of Medicine, The University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Nicholas S Hopkinson
- National Heart and Lung Institute, Imperial College, Royal Brompton Hospital Campus, London, UK
| | - Ravi Mahadeva
- Department of Medicine, Cambridge NIHR BRC, University of Cambridge, Leicester, UK
| | - Michael Steiner
- NIHR Leicester Biomedical Research Centre - Respiratory, Institute for Lung Health, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Tom Wilkinson
- Respiratory BRU, University of Southampton, Southampton, UK
| | | | - Bibek Gooptu
- NIHR Leicester Biomedical Research Centre - Respiratory, Institute for Lung Health, University of Leicester, Glenfield Hospital, Leicester, UK
- King's College London, Guy's Hospital Site, Great Maze Pond, London
| | - Robert A Stockley
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, UK
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Xia RY, Hu XY, Fei YT, Willcox M, Wen LZ, Yu MK, Zhang LS, Dai MY, Fei GH, Thomas M, Francis N, Wilkinson T, Moore M, Liu JP. Shufeng Jiedu capsules for treating acute exacerbations of chronic obstructive pulmonary disease: a systematic review and meta-analysis. BMC Complement Med Ther 2020; 20:151. [PMID: 32448238 PMCID: PMC7245765 DOI: 10.1186/s12906-020-02924-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 04/14/2020] [Indexed: 01/22/2023] Open
Abstract
Background Chinese herbal medicine is widely used in combination with usual care for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in China. Chinese patent medicine Shufeng Jiedu (SFJD) capsules is widely used for respiratory infectious diseases. This review aims to evaluate effectiveness and safety of SFJD for AECOPD. Methods A systematic review of randomised controlled trials (RCTs) in patients with AECOPD, who received SFJD as a single intervention or as add-on treatment to usual care. PubMed, the Cochrane Library, EMBASE, Scopus, Web of Science and four Chinese databases were searched from inception to April 2019. Two authors screened trials, extracted data, and assessed risk of bias, independently. Meta-analysis was performed using RevMan 5.3 software. We performed subgroup analyses and sensitivity analyses according to the predefined protocol. Quality of evidence was assessed using GRADE. Results Thirteen RCTs (1036 patients, with 936 inpatients) were included, all compared SFJD in combination with usual care (including antibiotics) to usual care alone. The mean age of participants ranged from 52 to 67 years, with approximately 60% male. Due to lack of blinding and other factors, all trials were of high risk of bias. SFJD was associated with a significant reduction in treatment failure, from 20.1 to 8.3% (11 trials; 815 patients; relative risk 0.43, 95% confidence interval [CI] 0.30 to 0.62), and duration of hospital stay (2 trials; 79 patients; mean difference − 4.32 days, 95% CI − 5.89 to − 2.75 days). No significant difference in adverse events was found between SFJD and control groups. Conclusion Low certainty evidence suggests SFJD may bring additional benefit in reducing treatment failure, shorten hospital stay, and improving symptoms. Further large, high quality RCTs are needed to confirm its benefit and safety. Trial registration PROSPERO CRD42019133682.
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Affiliation(s)
- Ru-Yu Xia
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11 North Sanhuan East Road, Chaoyang District, Beijing, 100029, China
| | - Xiao-Yang Hu
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Yu-Tong Fei
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11 North Sanhuan East Road, Chaoyang District, Beijing, 100029, China
| | - Merlin Willcox
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Ling-Zi Wen
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11 North Sanhuan East Road, Chaoyang District, Beijing, 100029, China
| | - Ming-Kun Yu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11 North Sanhuan East Road, Chaoyang District, Beijing, 100029, China
| | - Li-Shan Zhang
- Respiratory Department, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, No.5 Hai Yun Cang, Dongcheng District, Beijing, 100700, China
| | - Meng-Yuan Dai
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Anhui Medical University, No.210 Jixi Road, shushan District, Hefei, 230022, Anhui Province, China
| | - Guang-He Fei
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Anhui Medical University, No.210 Jixi Road, shushan District, Hefei, 230022, Anhui Province, China
| | - Mike Thomas
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Nick Francis
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Tom Wilkinson
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | - Michael Moore
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Jian-Ping Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11 North Sanhuan East Road, Chaoyang District, Beijing, 100029, China. .,Institute of Integrated Traditional Chinese Medicine and Western Medicine, Guangzhou Medical University, Guangzhou, 510120, China.
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Watson A, Spalluto CM, McCrae C, Cellura D, Burke H, Cunoosamy D, Freeman A, Hicks A, Hühn M, Ostridge K, Staples KJ, Vaarala O, Wilkinson T. Dynamics of IFN-β Responses during Respiratory Viral Infection. Insights for Therapeutic Strategies. Am J Respir Crit Care Med 2020; 201:83-94. [PMID: 31461630 DOI: 10.1164/rccm.201901-0214oc] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Rationale: Viral infections are major drivers of exacerbations and clinical burden in patients with asthma and chronic obstructive pulmonary disease (COPD). IFN-β is a key component of the innate immune response to viral infection. To date, studies of inhaled IFN-β treatment have not demonstrated a significant effect on asthma exacerbations.Objectives: The dynamics of exogenous IFN-β activity were investigated to inform on future clinical indications for this potential antiviral therapy.Methods: Monocyte-derived macrophages (MDMs), alveolar macrophages, and primary bronchial epithelial cells (PBECs) were isolated from healthy control subjects and patients with COPD and infected with influenza virus either prior to or after IFN-β stimulation. Infection levels were measured by the percentage of nucleoprotein 1-positive cells using flow cytometry. Viral RNA shedding and IFN-stimulated gene expression were measured by quantitative PCR. Production of inflammatory cytokines was measured using MSD.Measurements and Main Results: Adding IFN-β to MDMs, alveolar macrophages, and PBECs prior to, but not after, infection reduced the percentage of nucleoprotein 1-positive cells by 85, 56, and 66%, respectively (P < 0.05). Inhibition of infection lasted for 24 hours after removal of IFN-β and was maintained albeit reduced up to 1 week in MDMs and 72 hours in PBECs; this was similar between healthy control subjects and patients with COPD. IFN-β did not induce inflammatory cytokine production by MDMs or PBECs but reduced influenza-induced IL-1β production by PBECs.Conclusions: In vitro modeling of IFN-β dynamics highlights the potential for intermittent prophylactic doses of exogenous IFN-β to modulate viral infection. This provides important insights to aid the future design of clinical trials of IFN-β in asthma and COPD.
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Affiliation(s)
- Alastair Watson
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, and.,NIHR Southampton Biomedical Research Centre, Southampton Centre for Biomedical Research, Southampton General Hospital, Southampton, UK
| | - C Mirella Spalluto
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, and.,NIHR Southampton Biomedical Research Centre, Southampton Centre for Biomedical Research, Southampton General Hospital, Southampton, UK
| | - Christopher McCrae
- Bioscience, Research and Early Development-Respiratory, Inflammation and Autoimmunity, R&D BioPharmaceuticals, AstraZeneca, Gaithersburg, Maryland
| | - Doriana Cellura
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, and
| | - Hannah Burke
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, and.,NIHR Southampton Biomedical Research Centre, Southampton Centre for Biomedical Research, Southampton General Hospital, Southampton, UK
| | | | - Anna Freeman
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, and.,NIHR Southampton Biomedical Research Centre, Southampton Centre for Biomedical Research, Southampton General Hospital, Southampton, UK
| | - Alex Hicks
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, and.,NIHR Southampton Biomedical Research Centre, Southampton Centre for Biomedical Research, Southampton General Hospital, Southampton, UK
| | - Michael Hühn
- Translational Science and Experimental Medicine, and
| | - Kristoffer Ostridge
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, and.,NIHR Southampton Biomedical Research Centre, Southampton Centre for Biomedical Research, Southampton General Hospital, Southampton, UK.,Clinical Development, Research and Early Development-Respiratory, Inflammation and Autoimmunity, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | - Karl J Staples
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, and.,NIHR Southampton Biomedical Research Centre, Southampton Centre for Biomedical Research, Southampton General Hospital, Southampton, UK
| | - Outi Vaarala
- Bioscience, Research and Early Development-Respiratory, Inflammation and Autoimmunity, R&D BioPharmaceuticals, AstraZeneca, Gaithersburg, Maryland
| | - Tom Wilkinson
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, and.,NIHR Southampton Biomedical Research Centre, Southampton Centre for Biomedical Research, Southampton General Hospital, Southampton, UK
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Schnier C, Wilkinson T, Akbari A, Orton C, Sleegers K, Gallacher J, Lyons RA, Sudlow C. The Secure Anonymised Information Linkage databank Dementia e-cohort (SAIL-DeC). Int J Popul Data Sci 2020; 5:1121. [PMID: 32935048 PMCID: PMC7473277 DOI: 10.23889/ijpds.v5i1.1121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Introduction The rising burden of dementia is a global concern, and there is a need to study its causes, natural history and outcomes. The Secure Anonymised Information Linkage (SAIL) Databank contains anonymised, routinely-collected healthcare data for the population of Wales, UK. It has potential to be a valuable resource for dementia research owing to its size, long follow-up time and prospective collection of data during clinical care. Objectives We aimed to apply reproducible methods to create the SAIL dementia e-cohort (SAIL-DeC). We created SAIL-DeC with a view to maximising its utility for a broad range of research questions whilst minimising duplication of effort for researchers. Methods SAIL contains individual-level, linked primary care, hospital admission, mortality and demographic data. Data are currently available until 2018 and future updates will extend participant follow-up time. We included participants who were born between 1st January 1900 and 1st January 1958 and for whom primary care data were available. We applied algorithms consisting of International Classification of Diseases (versions 9 and 10) and Read (version 2) codes to identify participants with and without all-cause dementia and dementia subtypes. We also created derived variables for comorbidities and risk factors. Results From 4.4 million unique participants in SAIL, 1.2 million met the cohort inclusion criteria, resulting in 18.8 million person-years of follow-up. Of these, 129,650 (10%) developed all-cause dementia, with 77,978 (60%) having dementia subtype codes. Alzheimer's disease was the most common subtype diagnosis (62%). Among the dementia cases, the median duration of observation time was 14 years. Conclusion We have created a generalisable, national dementia e-cohort, aimed at facilitating epidemiological dementia research.
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Affiliation(s)
- C Schnier
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - T Wilkinson
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - A Akbari
- Health Data Research UK Wales and Northern Ireland, Swansea University, Swansea, UK.,Administrative Data Research Partnership Wales, Swansea University, Swansea, UK
| | - C Orton
- Health Data Research UK Wales and Northern Ireland, Swansea University, Swansea, UK
| | - K Sleegers
- Center for Molecular Neurology, University of Antwerp, Antwerp, Belgium
| | - J Gallacher
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - R A Lyons
- Health Data Research UK Wales and Northern Ireland, Swansea University, Swansea, UK.,National Centre for Population Health and Wellbeing Research, Swansea University, Swansea, UK
| | - Clm Sudlow
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Health Data Research UK Scotland, University of Edinburgh, Edinburgh, UK
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Abstract
Chronic obstructive pulmonary disease (COPD) affects one-tenth of the world's population and has been identified as a major global unmet health need by the World Health Organisation, which predicts that within 10 years, COPD will become the third leading cause of death. Despite active research, there have been no recent major strides in terms of disease modifying treatment for COPD; smoking cessation remains the only intervention known to alter disease progression and improve mortality. As established COPD is a key driver of disease burden, earlier diagnosis coupled with disease-modifying intervention carries promise as a route to address this global health priority. The concept of early COPD is emerging as an area of focus for research and consideration of new treatment modalities, as it has been hypothesised that intervention at this stage may potentially halt or reverse the disease process. However, at present, a globally accepted criteria for defining early COPD does not exist. Several studies propose small airways disease as the earliest stage in the development of COPD, and this has been demonstrated to be a precursor to development of emphysema and to correlate with subsequent development of airflow obstruction. However, treatment strategies for early disease, which pre-date the development of airflow obstruction, remain uncertain. This review addresses the rationale and current evidence base for the diagnosis and treatment of early COPD and highlights the challenges of implementing trials and clinical pathways to address COPD earlier in the life course, particularly in the absence of a universally accepted definition of COPD.The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Aishath Fazleen
- University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire SO16 6YD, UK
- Faculty of Medicine, University of Southampton, Hampshire, UK
| | - Tom Wilkinson
- University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire, UK
- Faculty of Medicine, University of Southampton, Hampshire, UK
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Wilkinson T. Student Politics in British India and Beyond: The Rise and Fragmentation of the All India Student Federation (AISF), 1936–1950. samaj 2019. [DOI: 10.4000/samaj.6488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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48
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Johnson M, Rigge L, Culliford D, Josephs L, Thomas M, Wilkinson T. Primary care risk stratification in COPD using routinely collected data: a secondary data analysis. NPJ Prim Care Respir Med 2019; 29:42. [PMID: 31797867 PMCID: PMC6892877 DOI: 10.1038/s41533-019-0154-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022] Open
Abstract
Most clinical contacts with chronic obstructive pulmonary disease (COPD) patients take place in primary care, presenting opportunity for proactive clinical management. Electronic health records could be used to risk stratify diagnosed patients in this setting, but may be limited by poor data quality or completeness. We developed a risk stratification database algorithm using the DOSE index (Dyspnoea, Obstruction, Smoking and Exacerbation) with routinely collected primary care data, aiming to calculate up to three repeated risk scores per patient over five years, each separated by at least one year. Among 10,393 patients with diagnosed COPD, sufficient primary care data were present to calculate at least one risk score for 77.4%, and the maximum of three risk scores for 50.6%. Linked secondary care data revealed primary care under-recording of hospital exacerbations, which translated to a slight, non-significant cohort average risk score reduction, and an understated risk group allocation for less than 1% of patients. Algorithmic calculation of the DOSE index is possible using primary care data, and appears robust to the absence of linked secondary care data, if unavailable. The DOSE index appears a simple and practical means of incorporating risk stratification into the routine primary care of COPD patients, but further research is needed to evaluate its clinical utility in this setting. Although secondary analysis of routinely collected primary care data could benefit clinicians, patients and the health system, standardised data collection and improved data quality and completeness are also needed.
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Affiliation(s)
- Matthew Johnson
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.
- NIHR ARC Wessex Data Science Hub, Faculty of Health Sciences, University of Southampton, Southampton, UK.
| | - Lucy Rigge
- NIHR ARC Wessex, University of Southampton, Southampton, UK
- NIHR Respiratory Biomedical Research Unit, Southampton General Hospital, Southampton, UK
| | - David Culliford
- NIHR ARC Wessex Data Science Hub, Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Lynn Josephs
- NIHR ARC Wessex, University of Southampton, Southampton, UK
- Department of Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Mike Thomas
- NIHR ARC Wessex, University of Southampton, Southampton, UK
- NIHR Respiratory Biomedical Research Unit, Southampton General Hospital, Southampton, UK
- Department of Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Tom Wilkinson
- NIHR Respiratory Biomedical Research Unit, Southampton General Hospital, Southampton, UK
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK
- Wessex Investigational Sciences Hub, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK
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49
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50
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Azim A, Mistry H, Freeman A, Barber C, Newell C, Gove K, Thirlwall Y, Harvey M, Bentley K, Knight D, Long K, Mitchell F, Cheng Y, Varkonyi-Sepp J, Grabau W, Dennison P, Haitchi HM, Arshad SH, Djukanovic R, Wilkinson T, Howarth P, Kurukulaaratchy RJ. Protocol for the Wessex AsThma CoHort of difficult asthma (WATCH): a pragmatic real-life longitudinal study of difficult asthma in the clinic. BMC Pulm Med 2019; 19:99. [PMID: 31126281 PMCID: PMC6534885 DOI: 10.1186/s12890-019-0862-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 05/15/2019] [Indexed: 01/19/2023] Open
Abstract
Background Asthma is now widely recognised to be a heterogeneous disease. The last two decades have seen the identification of a number of biological targets and development of various novel therapies. Despite this, asthma still represents a significant health and economic burden worldwide. Why some individuals should continue to suffer remains unclear. Methods The Wessex Asthma Cohort of Difficult Asthma (WATCH) is an ongoing ‘real-life’, prospective study of patients in the University Hospital Southampton Foundation Trust (UHSFT) Difficult Asthma service. Research data capture is aligned with the extensive clinical characterisation required of a commissioned National Health Service (NHS) Specialist Centre for Severe Asthma. Data acquisition includes detailed clinical, health and disease-related questionnaires, anthropometry, allergy and lung function testing, radiological imaging (in a small subset) and collection of biological samples (blood, urine and sputum). Prospective data are captured in parallel to clinical follow up appointments, with data entered into a bespoke database. Discussion The pragmatic ongoing nature of the WATCH study allows comprehensive assessment of the real world clinical spectrum seen in a Specialist Asthma Centre and allows a longitudinal perspective of deeply phenotyped patients. It is anticipated that the WATCH cohort would act as a vehicle for potential collaborative asthma studies and will build upon our understanding of mechanisms underlying difficult asthma. Electronic supplementary material The online version of this article (10.1186/s12890-019-0862-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adnan Azim
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Heena Mistry
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK
| | - Anna Freeman
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Clair Barber
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Colin Newell
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kerry Gove
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Yvette Thirlwall
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Matt Harvey
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kimberley Bentley
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Deborah Knight
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Karen Long
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Frances Mitchell
- The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK
| | - Yueqing Cheng
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Judit Varkonyi-Sepp
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Paddy Dennison
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Hans Michael Haitchi
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Institute for Life Sciences, University of Southampton, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - S Hasan Arshad
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Institute for Life Sciences, University of Southampton, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK
| | - Ratko Djukanovic
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Tom Wilkinson
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Institute for Life Sciences, University of Southampton, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Peter Howarth
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Institute for Life Sciences, University of Southampton, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ramesh J Kurukulaaratchy
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK. .,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK. .,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK. .,The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK. .,Respiratory Medicine & Allergy, Asthma, Allergy & Clinical Immunology, Mailpoint 52, Floor 2 Minerva House, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, UK.
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