Intrauterine contraception (2021)

Type of publication:
Journal article

Author(s):
*Ritchie J.; Phelan N.; Briggs P.

Citation:
Obstetrician and Gynaecologist; Jul 2021; vol. 23 (no. 3); p. 187-195

Abstract:
Key content: An intrauterine device (IUD), also known as intrauterine contraceptive device (IUCD) or intrauterine contraception (IUC) offers reliable long-acting reversible contraception; however, some patients can be hesitant to choose this option because of misconceptions about side effects and perceived complications. A comprehensive knowledge of IUC is required to allow adequate counselling and to dispel myths. There are many different methods of IUC, including four different levonorgestrel-containing intrauterine systems (LNG-IUS) and multiple different copper intrauterine devices, with different insertion techniques. Considering contraception is important at several life stages, including post-delivery, post-termination of pregnancy and around the menopause; these will require different counselling. The use of IUC can have noncontraceptive benefits, including relief of heavy menstrual bleeding, management of menopause and premenstrual syndrome and reducing gynaecological cancer risk. Learning objectives: To learn the different types of IUC, including the different indications and possible complications. To understand the noncontraceptive benefits of IUC. To understand the challenges faced when a patient is hesitant to consider IUC

Link to full-text [NHS OpenAthens account required]

An international genome-wide meta-analysis of primary biliary cholangitis: Novel risk loci and candidate drugs (2021)

Type of publication:
Systematic Review

Author(s):
Cordell H.J.; Fryett J.J.; Darlay R.; Ueno K.; Khor S.-S.; Kawai Y.; Tokunaga K.; Aiba Y.; Nakamura M.; Hitomi Y.; Kawashima M.; Nishida N.; Gervais O.; Nagasaki M.; Tang R.; Ma X.; Shi Y.; Li Z.; Juran B.D.; Cheung A.; Lazaridis K.N.; Atkinson E.J.; de Andrade M.; Gerussi A.; Carbone M.; Invernizzi P.; Cristoferi L.; D'Amato D.; Malinverno F.; Mancuso C.; Massironi S.; Milani C.; Ronca V.; Asselta R.; Baras A.; Horowitz J.; Ferreira M.A.R.; Sun D.; Jones D.E.; Flack S.; Spicer A.; Mulcahy V.L.; Sandford R.N.; Mells G.F.; Byan J.; Han Y.; Amos C.I.; Hirschfield G.M.; Seldin M.F.; Siminovitch K.A.; Mason A.; Vincent C.; Xie G.; Zhang J.; Affronti A.; Almasio P.L.; Alvaro D.; Andreone P.; Andriulli A.; Azzaroli F.; Battezzati P.M.; Benedetti A.; Bragazzi M.; Brunetto M.; Bruno S.; Calvaruso V.; Cardinale V.; Casella G.; Cazzagon N.; Ciaccio A.; Coco B.; Colli A.; Colloredo G.; Colombo M.; Colombo S.; Cursaro C.; Croce L.S.; Crosignani A.; Donato F.; Elia G.; Ferrari C.; Fabris L.; Fagiuoli S.; Floreani A.; Galli A.; Marra F.; Giannini E.; Grattagliano I.; Lampertico P.; Lleo A.; Marzioni M.; Mattalia A.; Miele L.; Morini L.; Morisco F.; Muratori L.; Muratori P.; Niro G.A.; O'Donnell S.; Picciotto A.; Portincasa P.; Rigamonti C.; Rosina F.; Spinzi G.; Strazzabosco M.; Tarocchi M.; Tiribelli C.; Toniutto P.; Valenti L.; Vinci M.; Zuin M.; Nakamura H.; Abiru S.; Nagaoka S.; Komori A.; Yatsuhashi H.; Ishibashi H.; Ito M.; Migita K.; Ohira H.; Katsushima S.; Naganuma A.; Sugi K.; Komatsu T.; Mannami T.; Matsushita K.; Yoshizawa K.; Makita F.; Nikami T.; Nishimura H.; Kouno H.; Ota H.; Komura T.; Nakamura Y.; Shimada M.; Hirashima N.; Komeda T.; Ario K.; Nakamuta M.; Yamashita T.; Furuta K.; Kikuchi M.; Naeshiro N.; Takahashi H.; Mano Y.; Tsunematsu S.; Yabuuchi I.; Shimada Y.; Yamauchi K.; Sugimoto R.; Sakai H.; Mita E.; Koda M.; Tsuruta S.; Kamitsukasa H.; Sato T.; Masaki N.; Kobata T.; Fukushima N.; Ohara Y.; Muro T.; Takesaki E.; Takaki H.; Yamamoto T.; Kato M.; Nagaoki Y.; Hayashi S.; Ishida J.; Watanabe Y.; Kobayashi M.; Koga M.; Saoshiro T.; Yagura M.; Hirata K.; Tanaka A.; Takikawa H.; Zeniya M.; Abe M.; Onji M.; Kaneko S.; Honda M.; Arai K.; Arinaga-Hino T.; Hashimoto E.; Taniai M.; Umemura T.; Joshita S.; Nakao K.; Ichikawa T.; Shibata H.; Yamagiwa S.; Seike M.; Honda K.; Sakisaka S.; Takeyama Y.; Harada M.; Senju M.; Yokosuka O.; Kanda T.; Ueno Y.; Kikuchi K.; Ebinuma H.; Himoto T.; Yasunami M.; Murata K.; Mizokami M.; Kawata K.; Shimoda S.; Miyake Y.; Takaki A.; Yamamoto K.; Hirano K.; Ichida T.; Ido A.; Tsubouchi H.; Chayama K.; Harada K.; Nakanuma Y.; Maehara Y.; Taketomi A.; Shirabe K.; Soejima Y.; Mori A.; Yagi S.; Uemoto S.; H E.; Tanaka T.; Yamashiki N.; Tamura S.; Sugawara Y.; Kokudo N.; Chalasani N.; Luketic V.; Odin J.; Chopra K.; Abecasis G.; Cantor M.; Coppola G.; Economides A.; Lotta L.A.; Overton J.D.; Reid J.G.; Shuldiner A.; Beechert C.; Forsythe C.; Fuller E.D.; Gu Z.; Lattari M.; Lopez A.; Schleicher T.D.; Padilla M.S.; Toledo K.; Widom L.; Wolf S.E.; Pradhan M.; Manoochehri K.; Ulloa R.H.; Bai X.; Balasubramanian S.; Barnard L.; Blumenfeld A.; Eom G.; Habegger L.; Hawes A.; Khalid S.; Maxwell E.K.; Salerno W.; Staples J.C.; Jones M.B.; Mitnaul L.J.; Sturgess R.; Healey C.; Yeoman A.; Gunasekera A.V.; Kooner P.; Kapur K.; Sathyanarayana V.; Kallis Y.; Subhani J.; Harvey R.; McCorry R.; Rooney P.; Ramanaden D.; Evans R.; Mathialahan T.; Gasem J.; Shorrock C.; Bhalme M.; Southern P.; Tibble J.A.; Gorard D.A.; Jones S.; Mells G.; Mulcahy V.; Srivastava B.; Foxton M.R.; Collins C.E.; Elphick D.; Karmo M.; Porras-Perez F.; Mendall M.; Yapp T.; Patel M.; Ede R.; Sayer J.; Jupp J.; Fisher N.; Carter M.J.; Koss K.; Shah J.; Piotrowicz A.; Scott G.; Grimley C.; Gooding I.R.; Williams S.; Tidbury J.; Lim G.; Cheent K.; Levi S.; Mansour D.; Beckley M.; Hollywood C.; Wong T.; Marley R.; Ramage J.; Gordon H.M.; Ridpath J.; Ngatchu T.; Bob Grover V.P.; Shidrawi R.G.; Abouda G.; Corless L.; Narain M.; Rees I.; Brown A.; Taylor-Robinson S.; Wilkins J.; Grellier L.; Banim P.; Das D.; Heneghan M.A.; Curtis H.; Matthews H.C.; Mohammed F.; Aldersley M.; Srirajaskanthan R.; Walker G.; McNair A.; Sharif A.; Sen S.; Bird G.; Prince M.I.; Prasad G.; Kitchen P.; Barnardo A.; Oza C.; Sivaramakrishnan N.N.; Gupta P.; Shah A.; Evans C.D.; Saha S.; Pollock K.; Bramley P.; Mukhopadhya A.; Barclay S.T.; McDonald N.; Bathgate A.J.; Palmer K.; Dillon J.F.; Rushbrook S.M.; Przemioslo R.; McDonald C.; Millar A.; Tai C.; Mitchell S.; Metcalf J.; Shaukat S.; Ninkovic M.; Shmueli U.; Davis A.; Naqvi A.; Lee T.J.; Ryder S.; Collier J.; Klass H.; Cramp M.E.; Sharer N.; Aspinall R.; Ghosh D.; Douds A.C.; Booth J.; Williams E.; Hussaini H.; Christie J.; Mann S.; Thorburn D.; Marshall A.; Patanwala I.; Ala A.; Maltby J.; Matthew R.; Corbett C.; Vyas S.; Singhal S.; Gleeson D.; Misra S.; *Butterworth J.; George K.; Harding T.; Douglass A.; Mitchison H.; Panter S.; Shearman J.; Bray G.; Roberts M.; Butcher G.; Forton D.; Mahmood Z.; Cowan M.; Ch'ng C.L.; Rahman M.; Whatley G.C.A.; Wesley E.; Mandal A.; Jain S.; Pereira S.P.; Wright M.; Trivedi P.; Gordon F.H.; Unitt E.; Palejwala A.; Austin A.; Vemala V.; Grant A.; Higham A.D.; Brind A.; Mathew R.; Cox M.; Ramakrishnan S.; King A.; Whalley S.; Fraser J.; Thomson S.J.; Bell A.; Wong V.S.; Kia R.; Gee I.; Keld R.; Ransford R.; Gotto J.; Millson C.

Citation:
Journal of Hepatology; 2021

Abstract:
Backgrounds & Aims: Primary biliary cholangitis (PBC) is a chronic liver disease in which autoimmune destruction of the small intrahepatic bile ducts eventually leads to cirrhosis. Many patients have inadequate response to licensed medications, motivating the search for novel therapies. Previous genome-wide association studies (GWAS) and meta-analyses (GWMA) of PBC have identified numerous risk loci for this condition, providing insight into its aetiology. We undertook the largest GWMA of PBC to date, aiming to identify additional risk loci and prioritise candidate genes for in silico drug efficacy screening.
Method(s): We combined new and existing genotype data for 10,516 cases and 20,772 controls from 5 European and 2 East Asian cohorts.
Result(s): We identified 56 genome-wide significant loci (20 novel) including 46 in European, 13 in Asian, and 41 in combined cohorts; and a 57th genome-wide significant locus (also novel) in conditional analysis of the European cohorts. Candidate genes at newly identified loci include FCRL3, INAVA, PRDM1, IRF7, CCR6, CD226, and IL12RB1, which each play key roles in immunity. Pathway analysis reiterated the likely importance of pattern recognition receptor and TNF signalling, JAK-STAT signalling, and differentiation of T helper (TH)1 and TH17 cells in the pathogenesis of this disease. Drug efficacy screening identified several medications predicted to be therapeutic in PBC, some of which are well-established in the treatment of other autoimmune
disorders.
Conclusion(s): This study has identified additional risk loci for PBC, provided a hierarchy of agents that could be trialled in this condition, and emphasised the value of genetic and genomic approaches to drug discovery in complex disorders. Lay summary: Primary biliary cholangitis (PBC) is a chronic liver disease that eventually leads to cirrhosis. In this study, we analysed genetic information from 10,516 people with PBC and 20,772 healthy individuals recruited in Canada, China, Italy, Japan, the UK, or the USA. We identified several genetic regions associated with PBC. Each of these regions contains several genes. For each region, we used diverse sources of evidence to help us choose the gene most likely to be involved in causing PBC. We used these
'candidate genes' to help us identify medications that are currently used for treatment of other conditions, which might also be useful for treatment of PBC.

Improving outcomes for older people with diabetes (2021)

Type of publication:
Journal article

Author(s):
*Morris, David

Citation:
Practice Nursing; Jul 2021; vol. 32 (no. 7); p. 270-276

Abstract:
Older people with diabetes have unique challenges. David Morris discusses the importance of individualising care for this group of people An individualised approach aiming to maximise safety, preserve autonomy and improve quality of life is needed when helping an older person to manage their diabetes. It is important to interpret the older person's diabetes in the context of their overall health concerns, including reference to co-morbidities, cognitive function, lifestyle, social setting, and life expectancy, and practice nurses are well placed to work in partnership with people with diabetes to achieve this. Pharmacological treatment goals must be realistic, acknowledging the metabolic consequences of old age, the risks of hypoglycaemia and the dangers of
polypharmacy.

A UK Expert Consensus Approach for Managing Symptomatic Arteriovenous Fistula (AVF) Stenosis in Haemodialysis Patients (2021)

Type of publication:
Journal article

Author(s):
Jaffer, Ounali; Gibbs, Paul; Gibson, Matthew; Gilbert, James; Hanko, Jennifer; Jeevaratnam, Praveen; Jones, Robert; *Nicholas, Johann; Ramnarine, Raymond; Sivaprakasam, Rajesh; Steiner, Kate; Tippett, Richard; Wilkins, Jason

Citation:
Cardiovascular and interventional radiology; Nov 2021; vol. 44 (no. 11); p. 1736-1746

Abstract:
PURPOSE Stenoses in mature arteriovenous fistulas (AVFs) are common and can negatively impact on the quality of haemodialysis, the longevity of the AVF and lead to debilitating symptoms. Multiple treatment options exist; however, management can vary between different centres. We aimed to establish multidisciplinary consensus on the optimal stepwise application of interventions based on evidence and consensus. METHODS A modified Delphi process was conducted with 13 participants from hospitals across the UK, all of whom have high-volume dialysis access practice. RESULTS The usual intervention to rectify de novo stenoses of mature AVFs is fistuloplasty, although surgery for inflow segment stenoses is also clinically acceptable. Appropriate first-line interventions include plain old balloon angioplasty or high-pressure balloon angioplasty; if these fail during the fistuloplasty, consider upsizing the balloon, prolonged balloon inflation or using alternative interventions, such as cutting or scoring balloons and ultra-high-pressure balloons. Alternative or subsequent interventions vary by anatomical site and may require additional multidisciplinary team input. For a stenoses recurring between 3 and 12 months, it is appropriate to consider interventions used de novo, but with a lower threshold for using drug-coated balloons (DCBs) in all regions and for using stent grafts in all regions but inflow segment. Recurrence after 12 months should be treated as a de novo lesion, with DCBs considered if they have been used successfully during previous interventions. CONCLUSIONS These recommendations aim to provide a practical guide to multidisciplinary teams in order to optimise the use of multiple interventions for rectifying AVF stenoses and provide unified evidence-based practice guidelines.

Requirement of interventional treatment in a patient being conservatively managed for persistent pneumothorax over a prolonged period (2021)

Type of publication:
Journal article

Author(s):
*Brenac, Sophia

Citation:
BMJ case reports; Jul 2021; vol. 14 (no. 7)

Abstract:
An 85-year-old ex-smoker being managed conservatively over 2 years for a small right apical pneumothorax presented to the respiratory clinic with suddenly worsening shortness of breath and chest pain. A chest radiograph demonstrated sudden deterioration in the size of his pneumothorax. Previous CT scans had found emphysematous cystic changes within the lungs, and his new presentation warranted definitive surgical intervention with a right bullectomy and talc pleurodesis through a video-assisted thoracoscopic surgery procedure. The patient made a good recovery and was discharged from clinic a year later. This case demonstrates the importance of follow-up in patients with unresolved pneumothoraces due to the potential for sudden deterioration, and highlights the significance of respecting patient involvement and autonomy in the decision-making process.

Link to full-text [NHS OpenAthens account required]

Non-drug therapies for the management of chronic constipation in adults: the CapaCiTY research programme including three RCTs (2021)

Type of publication:
Journal article

Author(s):
Knowles, Charles H; Booth, Lesley; Brown, Steve R; Cross, Samantha; Eldridge, Sandra; Emmett, Christopher; Grossi, Ugo; Jordan, Mary; *Lacy-Colson, Jon; Mason, James; McLaughlin, John; Moss-Morris, Rona; Norton, Christine; Scott, S Mark; Stevens, Natasha; Taheri, Shiva; Yiannakou, Yan.

Citation:
NIHR Journals Library. Programme Grants for Applied Research 2021 Vol 9(14).

Abstract:
BACKGROUND: Chronic constipation affects 1-2% of adults and significantly affects quality of life. Beyond the use of laxatives and other basic measures, there is uncertainty about management, including the value of specialist investigations, equipment-intensive therapies using biofeedback, transanal irrigation and surgery. OBJECTIVES: (1) To determine whether or not standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback is more clinically effective than standardised specialist-led habit training alone, and whether or not outcomes of such specialist-led interventions are improved by stratification to habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or habit training alone based on prior knowledge of anorectal and colonic pathophysiology using standardised radiophysiological investigations; (2) to compare the impact of transanal irrigation initiated with low-volume and high-volume systems on patient disease-specific quality of life; and (3) to determine the clinical efficacy of laparoscopic ventral mesh rectopexy compared with controls at short-term follow-up. DESIGN: The Chronic Constipation Treatment Pathway (CapaCiTY) research programme was a programme of national recruitment with a standardised methodological framework (i.e. eligibility, baseline phenotyping and standardised outcomes) for three randomised trials: a parallel three-group trial, permitting two randomised comparisons (CapaCiTY trial 1), a parallel two-group trial (CapaCiTY trial 2) and a stepped-wedge (individual-level) three-group trial (CapaCiTY trial 3). SETTING: Specialist hospital centres across England, with a mix of urban and rural referral bases. PARTICIPANTS: The main inclusion criteria were as follows: age 18-70 years, participant self-reported problematic constipation, symptom onset > 6 months before recruitment, symptoms meeting the American College of Gastroenterology's constipation definition and constipation that failed treatment to a minimum basic standard. The main exclusion criteria were secondary constipation and previous experience of study interventions. INTERVENTIONS: CapaCiTY trial 1: group 1 – standardised specialist-led habit training alone (n = 68); group 2 – standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (n = 68); and group 3 – standardised radiophysiological investigations-guided treatment (n = 46) (allocation ratio 3 : 3 : 2, respectively). CapaCiTY trial 2: transanal irrigation initiated with low-volume (group 1, n = 30) or high-volume (group 2, n = 35) systems (allocation ratio 1 : 1). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy performed immediately (n = 9) and after 12 weeks' (n = 10) and after 24 weeks' (n = 9) waiting time (allocation ratio 1 : 1 : 1, respectively). MAIN OUTCOME MEASURES: The main outcome measures were standardised outcomes for all three trials. The primary clinical outcome was mean change in Patient Assessment of Constipation Quality of Life score at the 6-month, 3-month or 24-week follow-up. The secondary clinical outcomes were a range of validated disease-specific and psychological scoring instrument scores. For cost-effectiveness, quality-adjusted life-year estimates were determined from individual participant-level cost data and EuroQol-5 Dimensions, five-level version, data. Participant experience was investigated through interviews and qualitative analysis. RESULTS: A total of 275 participants were recruited. Baseline phenotyping demonstrated high levels of symptom burden and psychological morbidity. CapaCiTY trial 1: all interventions (standardised specialist-led habit training alone, standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback and standardised radiophysiological investigations-guided habit training alone or habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback) led to similar reductions in the Patient Assessment of Constipation Quality of Life score (approximately -0.8 points), with no statistically significant difference between habit training alone and habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (-0.03 points, 95% confidence interval -0.33 to 0.27 points; p = 0.8445) or between standardised radiophysiological investigations and no standardised radiophysiological investigations (0.22 points, 95% confidence interval -0.11 to 0.55 points; p = 0.1871). Secondary outcomes reflected similar levels of benefit for all interventions. There was no evidence of greater cost-effectiveness of habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or stratification by standardised radiophysiological investigations compared with habit training alone (with the probability that habit training alone is cost-effective at a willingness-to-pay threshold of 30,000 per quality-adjusted life-year gain; p = 0.83). Participants reported mixed experiences and similar satisfaction in all groups in the qualitative interviews. CapaCiTY trial 2: at 3 months, there was a modest reduction in the Patient Assessment of Constipation Quality of Life score, from a mean of 2.4 to 2.2 points (i.e. a reduction of 0.2 points), in the low-volume transanal irrigation group compared with a larger mean reduction of 0.6 points in the high-volume transanal irrigation group (difference -0.37 points, 95% confidence interval -0.89 to 0.15 points). The majority of participants preferred high-volume transanal irrigation, with substantial crossover to high-volume transanal irrigation during follow-up. Compared with low-volume transanal irrigation, high-volume transanal irrigation had similar costs (median difference -8, 95% confidence interval -240 to 221) and resulted in significantly higher quality of life (0.093 quality-adjusted life-years, 95% confidence interval 0.016 to 0.175 quality-adjusted life-years). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy resulted in a substantial short-term mean reduction in the Patient Assessment of Constipation Quality of Life score (-1.09 points, 95% confidence interval -1.76 to -0.41 points) and beneficial changes in all other outcomes; however, significant increases in cost (5012, 95% confidence interval 4446 to 5322) resulted in only modest increases in quality of life (0.043 quality-adjusted life-years, 95% confidence interval -0.005 to 0.093 quality-adjusted life-years), with an incremental cost-effectiveness ratio of 115,512 per quality-adjusted life-year. CONCLUSIONS: Excluding poor recruitment and underpowering of clinical effectiveness analyses, several themes emerge: (1) all interventions studied have beneficial effects on symptoms and disease-specific quality of life in the short term; (2) a simpler, cheaper approach to nurse-led behavioural interventions appears to be at least as clinically effective as and more cost-effective than more complex and invasive approaches (including prior investigation); (3) high-volume transanal irrigation is preferred by participants and has better clinical effectiveness than low-volume transanal irrigation systems; and (4) laparoscopic ventral mesh rectopexy in highly selected participants confers a very significant short-term reduction in symptoms, with low levels of harm but little effect on general quality of life. LIMITATIONS: All three trials significantly under-recruited [CapaCiTY trial 1, n = 182 (target 394); CapaCiTY trial 2, n = 65 (target 300); and CapaCiTY trial 3, n = 28 (target 114)]. The numbers analysed were further limited by loss before primary outcome. TRIAL REGISTRATION: Current Controlled Trials ISRCTN11791740,
ISRCTN11093872 and ISRCTN11747152.

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Evidence-based use of newer agents in type 2 diabetes (2021)

Type of publication:
Journal article

Author(s):
*Morris, D.

Citation:
Journal of Prescribing Practice; Jun 2021; vol. 3 (no. 6); p. 224-234

Abstract:
The DPP-4 inhibitors, GLP-1 receptor agonists and SGLT-2 inhibitors are newer agents for glycaemic control in type 2 diabetes that can offer additional health benefits. All three treatments carry a low risk of hypoglycaemia. GLP-1 RAs and SGLT-2 inhibitors are associated with weight loss and DPP-4 inhibitors are weight neutral. The GLP-1 RAs and SGLT-2 inhibitors offer protection against cardiovascular events. SGLT-2 inhibitors are the agents of choice to add on to metformin for glycaemic control in chronic kidney disease and heart failure, with GLP-1 RAs an alternative to be considered if SGLT-2 inhibitors are poorly tolerated or contraindicated. DPP-4 inhibitors are very well tolerated. Gastrointestinal side-effects can be problematic with GLP-1 RAs though frequently these settle with time. Genital thrush is a common side-effect with SGLT-2 inhibitors and diabetic ketoacidosis is a rare but serious side-effect. It is important that healthcare professionals with responsibility in diabetes familiarise themselves with these treatments in order to know when and how to safely and effectively deploy them. The selection of newer agents should be based on careful assessment of individual circumstances. Overall, the standpoint has shifted from a largely glucocentric approach to one considering the impact of treatments on weight, risk of hypoglycaemia, and co-morbidities (notably atherosclerotic cardiovascular disease, heart failure and chronic kidney disease). Case histories are used in the article to illustrate the pragmatic use of these agents.

Genetic mechanisms of critical illness in COVID-19 (2021)

Type of publication:
Journal article

Author(s):
Pairo-Castineira E.; Clohisey S.; Rawlik K.; Parkinson N.; Fourman M.H.; Russell C.D.; Furniss J.; Wang B.; Griffiths F.; Oosthuyzen W.; Millar J.; Shih B.; Zechner M.; Haley C.; Meikle J.; Finernan P.; Mcmaster E.; Law A.; Baillie J.K.; Paterson T.; Wackett T.; Armstrong R.; Weaver J.; Boz C.; Golightly A.; Ward M.; Mal H.; SzoorMcElhinney H.; Brown A.; Hendry R.; Stenhouse A.; Cullum L.; Law D.; Law S.; Law R.; Swets M.; Day N.; Taneski F.; Duncan E.; Kenneth Baillie J.; Lyons R.; Tenesa A.; Klaric L.; Bretherick A.D.; Richmond A.; Meynert A.; Grimes G.; Hayward C.; Ponting C.; Meynert A.M.; Wham M.; Ponting C.P.; Vitart V.; Wilson J.F.; Pasko D.; Walker S.; Kousathanas A.; Moutsianas L.; Caulfield M.; Scott R.; Bogaert D.; Gountouna E.; Porteous D.J.; Wrobel N.; Clark R.; Coutts A.; Donnelly L.; Gilchrist T.; Hafezi K.; Macgillivray L.; Maclean A.; McCafferty S.; Morrice K.; Fawkes A.; Murphy L.; Harrison D.; Rowan K.; Wu Y.; Yang Z.; Zhai R.; Zheng C.; Shen X.; Beale R.; Keating S.; Walsh T.; Docherty A.B.; Yang J.; Knight J.; Klenerman P.; Summers C.; Shankar-Hari M.; Turtle L.; Moore S.C.; Solomon T.; Turtle L.C.W.; Hardwick H.; Semple M.G.; Ho A.; Hinds C.; Horby P.; Horby P.W.; Nichol A.; Maslove D.; Ling L.; McAuley D.; Montgomery H.; Pereira A.C.; Krieger J.E.; Marques E.; Jannes C.E.; Renieri A.; Mari F.; Daga S.; Baldassarri M.; Fallerini C.; Fava F.; Valentino F.; Doddato G.; Giliberti A.; Bruttini M.; Croci S.; Meloni I.; Frullanti E.; Di Sarno L.; Tommasi A.; Palmieri M.; Tita R.; Amitrano S.; Pinto A.M.; Mencarelli M.A.; Rizzo C.L.; Dunning J.; Thwaites R.S.; Openshaw P.J.M.; Collier D.; Wood S.; Zak A.; Borra C.; Matharu M.; May P.; Alldis Z.; Mitchelmore O.; Bowles R.; Easthope A.; Bibi F.; Lancoma-Malcolm I.; Gurasashvili J.; Pheby J.; Shiel J.; Bolton M.; Patel M.; Taylor M.; Zongo O.; Ebano P.; Harding P.; Astin-Chamberlain R.; Choudhury Y.; Cox A.; Kallon D.; Burton M.; Hall R.; Blowes S.; Prime Z.; Biddle J.; Prysyazhna O.; Newman T.; Tierney C.; Kassam J.; Ostermann M.; Campos S.; Bociek A.; Lim R.; Grau N.; Jones T.O.; Whitton C.; Marotti M.; Arbane G.; Bonner S.; Hugill K.; Reid J.; Welters I.; Waugh V.; Williams K.; Shaw D.; Roman J.F.; Martinez M.L.; Johnson E.; Waite A.; Johnston B.; Hamilton D.; Mulla S.; McPhail M.; Smith J.; Barclay L.; Hope D.; McCulloch C.; McQuillan L.; Clark S.; Singleton J.; Priestley K.; Rea N.; Callaghan M.; Campbell R.; Andrew G.; Marshall L.; McKechnie S.; Hutton P.; Bashyal A.; Davidson N.; Polgarova P.; Stroud K.; Pathan N.; Elston K.; Agrawal S.; Battle C.; Newey L.; Rees T.; Harford R.; Brinkworth E.; Williams M.; Murphy C.; White I.; Croft M.; Bandla N.; Gellamucho M.; Tomlinson J.; Turner H.; Davies M.; Quinn A.; Hussain I.; Thompson C.; Parker H.; Bradley R.; Griffiths R.; Scriven J.; Nilsson A.; Bates M.; Dasgin J.; Gill J.; Puxty A.; Cathcart S.; Salutous D.; Turner L.; Duffy K.; Puxty K.; Joseph A.; Herdman-Grant R.; Simms R.; Swain A.; Naranjo A.; Crowe R.; Sollesta K.; Loveridge A.; Baptista D.; Morino E.; Davey M.; Golden D.; Jones J.; Moreno Cuesta J.; Haldeos A.; Bakthavatsalam D.; Vincent R.; Elhassan M.; Xavier K.; Ganesan A.; Purohit D.; Abdelrazik M.; Morgan J.; Akeroyd L.; Bano S.; Lawton T.; Warren D.; Bromley M.; Sellick K.; Gurr L.; Wilkinson B.; Nagarajan V.; Szedlak P.; Cupitt J.; Stoddard E.; Benham L.; Preston S.; Laha S.; Slawson N.; Bradshaw Z.; Brown J.; Caswell M.; Melling S.; Bamford P.; Faulkner M.; Cawley K.; Jeffrey H.; London E.; Sainsbury H.; Nagra I.; Nasir F.; Dunmore C.; Jones R.; Abraheem A.; Al-Moasseb M.; Girach R.; Padden G.; Egan J.; Brantwood C.; Alexander P.; Bradley-Potts J.; Allen S.; Felton T.; Manna S.; Farnell-Ward S.; Leaver S.; Queiroz J.; Maccacari E.; Dawson D.; Delgado C.C.; Saluzzio R.P.; Ezeobu O.; Ding L.; Sicat C.; Kanu R.; Durrant G.; Texeira J.; Harrison A.; Samakomva T.; Willis H.; Hopkins B.; Thrasyvoulou L.; Jackson M.; Zaki A.; Tibke C.; Bennett S.; Woodyatt W.; Kent A.; Goodwin E.; Brandwood C.; Smith L.; Rooney K.; Thomson N.; Rodden N.; Hughes E.; McGlynn D.; Clark C.; Clark P.; Abel L.; Sundaram R.; Gemmell L.; Brett M.; Hornsby J.; MacGoey P.; Price R.; Digby B.; O'Neil P.; McConnell P.; Henderson P.; Henderson S.; Sim M.; Kennedy-Hay S.; McParland C.; Rooney L.; Baxter N.; Pogson D.; Rose S.; Daly Z.; Brimfield L.; Phull M.K.; Hussain M.; Pogreban T.; Rosaroso L.; Salciute E.; Grauslyte L.; Brealey D.; Raith E.; MacCallum N.; Bercades G.; Hass I.; Smyth D.; Reyes A.; Martir G.; Clement I.D.; Webster K.; Hays C.; Gulati A.; Hodgson L.; Margarson M.; Gomez R.; Baird Y.; Thirlwall Y.; Folkes L.; Butler A.; Meadows E.; Moore S.; Raynard D.; Fox H.; Riddles L.; King K.; Kimber S.; Hobden G.; McCarthy A.; Cannons V.; Balagosa I.; Chadbourn I.; Gardner A.; Horner D.; McLaughlanv D.; Charles B.; Proudfoot N.; Marsden T.; McMorrow L.; Blackledge B.; Pendlebury J.; Harvey A.; Apetri E.; Basikolo C.; Catlow L.; Doonan R.; Knowles K.; Lee S.; Lomas D.; Lyons C.; Perez J.; Poulaka M.; Slaughter M.; Slevin K.; Thomas V.; Walker D.; Harris J.; Drummond A.; Tully R.; Dearden J.; Philbin J.; Munt S.; Rishton C.; O'Connor G.; Mulcahy M.; Dobson E.; Cuttler J.; Edward M.; Norris J.; Hanson K.; Poole A.; Rose A.; Sloan B.; Buckley S.; Brooke H.; Smithson E.; Charlesworth R.; Sandhu R.; Thirumaran M.; Wagstaff V.; Suarez J.C.; Kaliappan A.; Vertue M.; Nicholson A.; Riches J.; Solesbury A.; Kittridge L.; Forsey M.; Maloney G.; Cole J.; Davies R.; Hill H.; Thomas E.; Williams A.; Duffin D.; Player B.; Radhakrishnan J.; Gibson S.; Lyle A.; McNeela F.; Patel B.; Gummadi M.; Sloane G.; Dormand N.; Salmi S.; Farzad Z.; Cristiano D.; Liyanage K.; Thwaites V.; Varghese M.; Meredith M.; Lim W.S.; Mills G.; Willson J.; Harrington K.; Lenagh B.; Cawthron K.; Masuko S.; Raithatha A.; Bauchmuller K.; Wiles M.; Ahmad N.; Barker J.; Jackson Y.; Kibutu F.; Bird S.; Watson G.; Martin J.; Bevan E.; Brown C.W.; Trodd D.; English K.; Bell G.; Wilcox L.; Katary A.; Gopal S.; Lake V.; Harris N.; Metherell S.; Radford E.; Moore F.; Bancroft H.; Daglish J.; Sangombe M.; Carmody M.; Rhodes J.; Bellamy M.; Garg A.; Kuravi A.; Virgilio E.; Ranga P.; Butler J.; Botfield L.; Dexter C.; Fletcher J.; Shanmugasundaram P.; Hambrook G.; Burn I.; Manso K.; Thornton D.; Tebbutt J.; Penn R.; Hulme J.; Hussain S.; Maqsood Z.; Joseph S.; Colley J.; Hayes A.; Ahmed C.; Haq R.; Clamp S.; Kumar R.; Purewal M.; Baines B.; Frise M.; Jacques N.; Coles H.; Caterson J.; Rai S.G.; Brunton M.; Tilney E.; Keating L.; Walden A.; Antcliffe D.; Brett S.; Gordon A.; Templeton M.; Rojo R.; Banach D.; Arias S.S.; Fernandez Z.; Coghlan P.; Williams D.; Jardine C.; Bewley J.; Sweet K.; Grimmer L.; Johnson R.; Garland Z.; Gumbrill B.; Phillips C.; Ortiz-Ruiz de Gordoa L.; Peasgood E.; Tridente A.; Shuker K.; Greer S.; Lynch C.; Pothecary C.; Roche L.; Deacon B.; Turner K.; Singh J.; Howe G.S.; Paul P.; Gill M.; Wynter I.; Ratnam V.; Shelton S.; Naisbitt J.; Melville J.; Baruah R.; Morrison S.; McGregor A.; Parris V.; Mpelembue M.; Srikaran S.; Dennis C.; Sukha A.; Verlander M.; Holding K.; Riches K.; Downes C.; Swan C.; Rostron A.; Roy A.; Woods L.; Cornell S.; Wakinshaw F.; Creagh-Brown B.; Blackman H.; Salberg A.; Smith E.; Donlon S.; Mtuwa S.; Michalak-Glinska N.; Stone S.; Beazley C.; Pristopan V.; Nikitas N.; Lankester L.; Wells C.; Raj A.S.; Fletcher K.; Khade R.; Tsinaslanidis G.; MacMahon M.; Fowler S.; Coventry T.; Stewart R.; Wren L.; Mwaura E.; Mew L.; Scaletta D.; Williams F.; Inweregbu K.; Lancaster N.; Cunningham M.; Daniels A.; Harrison L.; Hope S.; Jones S.; Crew A.; Wray G.; Matthews J.; Crawley R.; Carter J.; Birkinshaw I.; Ingham J.; Scott Z.; Pearson H.; Howard K.; Joy R.; Roche S.; Clark M.; Purvis S.; Morrison A.; Strachan D.; Clements S.; Black K.; Parmar C.; Altabaibeh A.; Simpson K.; Mostoles L.; Gilbert K.; Ma L.; Alvaro A.; Thomas M.; Faulkner B.; Worner R.; Hayes K.; Gendall E.; Blakemore H.; Borislavova B.; Goff E.; Vuylsteke A.; Mwaura L.; Zamikula J.; Garner L.; Mitchell A.; Mepham S.; Cagova L.; Fofano A.; Holcombe H.; Praman K.; Szakmany T.; Heron A.E.; Cherian S.; Cutler S.; Roynon-Reed A.; Randell G.; Convery K.; Stammers K.; Fottrell-Gould D.; Hudig L.; Keshet-Price J.; Peters M.; O'Neill L.; Ray S.; Belfield H.; McHugh T.; Jones G.; Akinkugbe O.; Tomas A.; Abaleke E.; Beech E.; Meghari H.; Yussuf S.; Bamford A.; Hairsine B.; Dooks E.; Farquhar F.; Packham S.; Bates H.; Armstrong L.; Kaye C.; Allan A.; Medhora J.; Liew J.; Botello A.; Anderson F.; Cusack R.; Golding H.; Prager K.; Williams T.; Leggett S.; Golder K.; Male M.; Jones O.; Criste K.; Marani M.; Anumakonda V.; Amin V.; Karthik K.; Kausar R.; Anastasescu E.; Reid K.; Smith M.; Hormis A.; Walker R.; Duncan T.; Uriel A.; Ustianowski A.; T-Michael H.; Bruce M.; Connolly K.; Smith K.; Partridge R.; Griffin D.; Mupudzi M.; Muchenje N.; Martin D.; Filipe H.; Eastgate C.; Jackson C.; Gratrix A.; Foster L.; Martinson V.; Stones E.; Abernathy C.; Parkinson P.; Reed A.; Prendergast C.; Rogers P.; Woodruff M.; Shokkar R.; Kaul S.; Barron A.; Collins C.; Beavis S.; Whileman A.; Dale K.; Hawes J.; Pritchard K.; Gascoyne R.; Stevenson L.; Jha R.; Lim L.; Krishnamurthy V.; Parker R.; Turner-Bone I.; Wilding L.; Reddy A.; Whiteley S.; Wilby E.; Howcroft C.; Aspinwall A.; Charlton S.; Ogg B.; Menzies D.; Pugh R.; Allan E.; Lean R.; Davies F.; Easton J.; Qiu X.; Kumar S.; Darlington K.; Houston G.; O'Brien P.; Geary T.; Allan J.; Meikle A.; Hughes G.; Balasubramaniam M.; Latham S.; McKenna E.; Flanagan R.; Sathe S.; Davies E.; Chablani M.; Kirkby A.; Netherton K.; Archer S.; Yates B.; Ashbrook-Raby C.; Cole S.; Casey M.; Cabrelli L.; Chapman S.; Hutcheon A.; Whyte C.; Almaden-Boyle C.; Pattison N.; Cruz C.; Vochin A.; Kent H.; Thomas A.; Murdoch S.; David B.; Penacerrada M.; Lubimbi G.; Bastion V.; Wulandari R.; Lorusso R.; Valentine J.; Clarke D.; Serrano-Ruiz A.; Hierons S.; Eckbad C.; Ramos L.; Demetriou C.; Mitchard S.; White K.; White N.; Pitts S.; Branney D.; Frankham J.; Watters M.; Langton H.; Prout R.; Page V.; Varghes T.; Cowton A.; Kay A.; Potts K.; Birt M.; Kent M.; Wilkinson A.; Jude E.B.; Turner V.; Savill H.; McCormick J.; Coulding M.; Siddiqui S.; Mercer O.; Rehman H.; Potla D.; *Capps N.; *Donaldson D.; *Button H.; *Martin T.; *Hard K.; *Agasou A.; *Tonks L.; *Arden T.; *Boyle P.; *Carnahan M.; *Strickley J.; *Adams C.; *Childs D.; *Rikunenko R.; *Leigh M.; *Breekes M.; *Wilcox R.; *Bowes A.; *Tiveran H.; *Hurford F.; *Summers J.; *Carter A.; *Hussain Y.; *Ting L.; *Javaid A.; *Motherwell N.; *Moore H.; *Millward H.; *Jose S.; *Schunki N.; *Noakes A.; *Clulow C.; Sadera G.; Jacob R.; Jones C.; Blunt M.; Coton Z.; Curgenven H.; Ally S.M.; Beaumont K.; Elsaadany M.; Fernandes K.; Ali Mohamed Ali I.; Rangarajan H.; Sarathy V.; Selvanayagam S.; Vedage D.; White M.; Truman N.; Chukkambotla S.; Keith S.; Cockerill-Taylor J.; Ryan-Smith J.; Bolton R.; Springle P.; Dykes J.; Thomas J.; Khan M.; Hijazi M.T.; Massey E.; Croston G.; Reschreiter H.; Camsooksai J.; Patch S.; Jenkins S.; Humphrey C.; Wadams B.; Msiska M.; Adanini O.; Attwood B.; Parsons P.; Tatham K.; Jhanji S.; Black E.; Dela Rosa A.; Howle R.; Thomas B.; Bemand T.; Raobaikady R.; Saha R.; Staines N.; Daniel A.; Finn J.; Hutter J.; Doble P.; Shovelton C.; Pawley C.; Kannan T.; Hill M.; Combes E.; Monnery S.; Joefield T.; Popescu M.; Thankachen M.; Oblak M.; Little J.; McIvor S.; Brady A.; Whittle H.; Prady H.; Chan R.; Ahmed A.; Morris A.; Gibson C.; Gordon E.; Keenan S.; Quinn H.; Benyon S.; Marriott S.; Zitter L.; Park L.; Baines K.; Lyons M.; Holland M.; Keenan N.; Young M.; Garrioch S.; Dawson J.; Tolson M.; Scholefield B.; Bi R.; Richardson N.; Schumacher N.; Cosier T.; Millen G.; Higham A.; Turki S.; Allen L.; Crisp N.; Hazleton T.; Knight A.; Deery J.; Price C.; Turney S.; Tilbey S.; Beranova E.; Wright D.; George L.; Twiss S.; Wadd S.; Postlethwaite K.; Gondo P.; Masunda B.; Kayani A.; Hadebe B.; Whiteside J.; Clarke N.; Donnison P.; Trim F.; Leadbitter I.; Butcher D.; O'Sullivan S.; Purewal B.; Bell S.; Rivers V.; O'Leary R.; Birch J.; Collins E.; Anderson S.; Hammerton K.; Andrews E.; Burns K.; Edmond I.; Todd A.; Donnachie J.; Turner P.; Prentice L.; Symon L.; Runciman N.; Auld F.; Halkes M.; Mercer P.; Thornton L.; Debreceni G.; Wilkins J.; Crickmore V.; Subramanian G.; Marshall R.; Jennings C.; Latif M.; Bunni L.; Spivey M.; Bean S.; Burt K.; Linnett V.; Ritzema J.; Sanderson A.; McCormick W.; Bokhari M.; Kapoor R.; Loader D.; Ayers A.; Harrison W.; North J.; Belagodu Z.; Paramsothy R.; Olufuwa O.; Gherman A.; Fuller B.; Stuart C.; Kelsall O.; Davis C.; Wild L.; Wood H.; Thrush J.; Durie A.; Austin K.; Archer K.; Anderson P.; Vigurs C.; Thorpe C.; Knights E.; Boyle N.; Price A.; Kubisz-Pudelko A.; Wood D.; Lewis A.; Board S.; Pippard L.; Perry J.; Beesley K.; Rattray A.; Lee E.; Lennon L.; Douglas K.; Bell D.; Boyle R.; Glass L.; Nauman Akhtar M.; Dent K.; Potoczna D.; Pearson S.; Horsley E.; Spencer S.; Mullan D.; Skinner D.; Gaylard J.; Barber R.; Hewitt C.; Hilldrith A.; Shepardson S.; Wills M.; Jackson-Lawrence K.; Gupta A.; Timlick E.; Gorman C.; Otahal I.; Gales A.; Coetzee S.; Sell C.; Raj M.; Peiu M.; Quaid S.; Watson E.; Elliott K.; Mallinson J.; Chandler B.; Turnbull A.; Finch C.; Holl C.; Cooper J.; Evans A.; Khaliq W.; Collins A.; Gude E.T.; Love N.; van Koutrik L.; Hunt J.; Kaye D.; Fisher E.; Brayne A.; Tuckey V.; Jackson P.; Parkin J.; Tariq A.; Houlden H.; Tucci A.; Hardy J.; Moncur E.; Highgate J.; Cowley A.; Mitra A.; Stead R.; Behan T.; Burnett C.; Newton M.; Heeney E.; Pollard R.; Hatton J.; Patel A.; Kasipandian V.; Allibone S.; Genetu R.M.; O'Brien L.; Omar Z.; Perkins E.; Davies K.; Tetla D.; Shelley B.; Irvine V.; Williams S.; Williams P.; Goodsell J.; Tutton R.; Bough L.; Winter-Goodwin B.; Kitson R.; Pinnell J.; Wilson A.; Nortcliffe T.; Wood T.; Home M.; Holdroyd K.; Robinson M.; Shaw R.; Greig J.; Brady M.; Haigh A.; Matupe L.; Usher M.; Mellor S.; Dale S.; Gledhill L.; Shaw L.; Turner G.; Kelly D.; Anwar B.; Riley H.; Sturgeon H.; Ali A.; Thomis L.; Melia D.; Dance A.; Humphreys S.; Frost I.; Gopal V.; Godden J.; Holden A.; Swann S.; Smith T.; Clapham M.; Poultney U.; Harper R.; Rice P.; Reece-Anthony R.; Gurung B.; Moultrie S.; Odam M.; Mayer A.; Bellini A.; Pickard A.; Bryant J.; Roe N.; Sowter J.; Lang K.; Taylor J.; Barry P.; Hobrok M.; Tench H.; Wolf-Roberts R.; McGuinness H.; Loosley R.; Hawcutt D.; Rad L.; O'Malley L.; Saunderson P.; Seddon G.; Anderson T.; Rogers N.; Ruddy J.; Harkins M.; Beith C.; McAlpine A.; Ferguson L.; Grant P.; MacFadyen S.; McLaughlin M.; Baird T.; Rundell S.; Welsh B.; Hamill R.; Fisher F.; Gregory J.; Campbell A.; Smuts S.; Carson G.; Merson L.; Sigfrid L.; Alex B.; Bach B.; Barclay W.S.; Chand M.; Cooke G.S.; Sriskandan S.; Harrison E.M.; Norman L.; Pius R.; Drake T.M.; Fairfield C.J.; Knight S.R.; Mclean K.A.; Murphy D.; Shaw C.A.; Zambon M.; da Silva Filipe A.; Ho A.Y.W.; Palmarini M.; Robertson D.L.; Scott J.T.; Thomson E.C.; McDonald S.; Fletcher T.; Green C.A.; Hiscox J.A.; Ijaz S.; Khoo S.; Mentzer A.J.; Noursadeghi M.; Paxton W.A.; Pollakis G.; Price N.; Rambaut A.; Sancho-Shimizu V.; de Silva T.; Stuart D.; Tedder R.S.; Thompson A.A.R.; Donohue C.; Dalton J.; Girvan M.; Saviciute E.; Roberts S.; Harrison J.; Marsh L.; Connor M.; Halpin S.; Gamble C.; Leeming G.; Greenhalf W.; Shaw V.; Ganna A.; Cordioli M.; Niemi M.E.K.; Sulem P.; Sveinbjornsson G.; van Heel D.A.; Shelton J.F.; Shastri A.J.; Ye C.; Weldon C.H.; FilshteinSonmez T.; Coker D.; Symons A.; Aslibekyan S.; Auton A.; Esparza-Gordillo J.; Benetti E.; Furini S.; Montagnani F.; Emiliozzi A.; Fabbiani M.; Rossetti B.; Zanelli G.; Bargagli E.; Bergantini L.; D'Alessandro M.; Cameli P.; Bennet D.; Anedda F.; Marcantonio S.; Scolletta S.; Franchi F.; Mazzei M.A.; Guerrini S.; Conticini E.; Cantarini L.; Frediani B.; Tacconi D.; Spertilli C.; Feri M.; Donati A.; Scala R.; Guidelli L.; Spargi G.; Corridi M.; Nencioni C.; Croci L.; Caldarelli G.P.; Spagnesi M.; Piacentini P.; Bandini M.; Desanctis E.; Cappelli S.; Canaccini A.; Verzuri A.; Anemoli V.; Ognibene A.; Vaghi M.; D'Arminio Monforte A.; Merlini E.; Mondelli M.U.; Mantovani S.; Ludovisi S.; Girardis M.; Venturelli S.; Sita M.; Cossarizza A.; Antinori A.; Vergori A.; Rusconi S.; Riva A.; Siano M.; Gabrieli A.; Francisci D.; Schiaroli E.; Scotton P.G.; Andretta F.; Panese S.; Scaggiante R.; Gatti F.; Parisi S.G.; Castelli F.; Quiros-Roldan M.E.; Magro P.; Zanella I.; Della Monica M.; Piscopo C.; Capasso M.; Russo R.; Andolfo I.; Iolascon A.; Fiorentino G.; Carella M.; Castori M.; Merla G.; Aucella F.; Raggi P.; Marciano C.; Perna R.; Bassetti M.; Di Biagio A.; Sanguinetti M.; Masucci L.; Valente S.; Mandala M.; Giorli A.; Salerni L.; Zucchi P.; Parravicini P.; Menatti E.; Baratti S.; Trotta T.; Giannattasio F.; Coiro G.; Lena F.; Coviello D.A.; Mussini C.; Bosio G.; Martinelli E.; Mancarella S.; Tavecchia L.; Crotti L.; Picchiotti N.; Gori M.; Gabbi C.; Sanarico M.; Ceri S.; Pinoli P.; Raimondi F.; Biscarini F.; Stella A.

Citation:
Nature; Mar 2021; vol. 591 (no. 7848); p. 92-98

Abstract:
Host-mediated lung inflammation is present1, and drives mortality2, in the critical illness caused by coronavirus disease 2019 (COVID-19). Host genetic variants associated with critical illness may identify mechanistic targets for therapeutic development3. Here we report the results of the GenOMICC (Genetics Of Mortality In Critical Care) genome-wide association study in 2,244 critically ill patients with COVID-19 from 208 UK intensive care units. We have identified and replicated the following new genome-wide significant associations: on chromosome 12q24.13 (rs10735079, P = 1.65 x 10-8) in a gene cluster that encodes antiviral restriction enzyme activators (OAS1, OAS2 and OAS3); on chromosome 19p13.2 (rs74956615, P = 2.3 x 10-8) near the gene that encodes tyrosine kinase 2 (TYK2); on chromosome 19p13.3 (rs2109069, P = 3.98 x 10-12) within the gene that encodes dipeptidyl peptidase 9 (DPP9); and on chromosome 21q22.1 (rs2236757, P = 4.99 x 10-8) in the interferon receptor gene IFNAR2. We identified potential targets for repurposing of licensed medications: using Mendelian randomization, we found evidence that low expression of IFNAR2, or high expression of TYK2, are associated with life-threatening disease; and transcriptome-wide association in lung tissue revealed that high expression of the monocyte-macrophage chemotactic receptor CCR2 is associated with severe COVID-19. Our results identify robust genetic signals relating to key host antiviral defence mechanisms and mediators of inflammatory organ damage in COVID-19. Both mechanisms may be amenable to targeted treatment with existing drugs. However, large-scale randomized clinical trials will be essential before any change to clinical practice

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A rare case of anti-NMDA receptor encephalitis associated with an ovarian teratoma (2021)

Type of publication:
Conference abstract

Author(s):
*Korrapati S.; *Sahu B.; *Parry-Smith W.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology; May 2021; vol. 128 ; p. 135

Abstract:
Introduction Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an auto-immune and paraneoplastic encephalitis with an incidence of 1.5 per million population per year. About 80% are women and nearly half of them have an ovarian teratoma. It is associated with antibodies against NR1 or NR2 subunits of NMDA receptor in cerebrospinal fluid (CSF) and serum. Given the rarity of occurrence, it remains an unrecognised entity among gynaecologists. Hence, we report a case of anti-NMDAR encephalitis associated with ovarian teratoma. Case report A 34-year-old woman attended under physicians with confusion, memory loss and agitation. She had a history of bilateral ovarian teratomas removed in 2018. Patient's vitals and neurological examination were normal. She was unable to perform motor tasks. Routine laboratory examinations and CT head were normal except for mild leucocytosis (WCC 13.3). She was empirically treated for infectious encephalitis. CSF examination showed normal glucose and protein, negative for viral PCR, gram staining but positive for NMDA receptor antibodies, prompting us to explore for an underlying tumour. CT abdomen/pelvis showed 9mm focus of fat suspicious of residual/recurrent teratoma in right adnexa. PET CT showed no metabolically active pathology. She was commenced on first line immunotherapy, IV Methylprednisolone followed by IV immunoglobulins and then plasma exchange. Following gynaecology MDT decision, she underwent laparoscopic right oophorectomy. Histopathology revealed a right ovarian teratoma. Postprocedure her neurological symptoms including confusion & memory retention improved considerably. Conclusion Anti-NMDAR encephalitis is rare but potentially debilitating condition. It is important to remove any associated ovarian teratoma promptly to improve outcome.

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A case of antepartum haemorrhage at 18 weeks gestation leading to DIC (2021)

Type of publication:
Journal article

Author(s):
*Barker V.; *Biswas N.; Brett-Miller C.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology; Jun 2021; vol. 128 ; p. 77

Abstract:
Objective A rare case of vaginal bleeding before 20 weeks' gestation with a 1.2 L blood loss leading to
Disseminated Intravascular Coagulation. Follow up of the case at 25 weeks gestation revealed an ongoing pregnancy with resolution of clotting function. Case report A 33 year old patient who had previously had six normal vaginal deliveries attended labour ward at 18 + 6 weeks gestation with pain, a sensation of pressure and a small amount of brown PV loss. She previously had a small bleed at 15 weeks' gestation when a subchorionic bleed was demonstrated on scan. Thirty minutes after arrival she started to bleed very heavily and within forty minutes had lost more than 1 litre of fresh blood. On examination she had a closed cervix with active ongoing bleeding. A bedside ultrasound scan revealed a viable pregnancy. Tranexamic acid 1 g was given intravenously. Clotting function on admission was markedly deranged; INR 2.4, prothrombin time 23.5, activated partial thromboplastin time 56, fibrinogen < 0.3 and D-Dimer 2157. Disseminated intravascular coagulation was diagnosed. Following discussion with the haematology consultant, she received two units of cryoprecipitate. The bleeding subsequently settled with total loss of 1.2 litres. She had further blood tests which showed normalisation of clotting function within 24 h. Departmental ultrasound scan showed no evidence of bleeding on scan but placenta was noted to extend to the cervix. Follow up at 25 weeks showed an ongoing pregnancy with no further bleeding. Discussion Disseminated Intravascular Coagulation is a rare complication of pregnancy and can be associated with a number of obstetric disorders including placental abruption and praevia, amniotic fluid embolism, intrauterine fetal demise, HELLP syndrome, preeclampsia/eclampsia, septic abortion, intrauterine infection, PPH and acute fatty liver of pregnancy. It can occur at any time in pregnancy but most commonly occurs in the 3rd trimester. DIC can be diagnosed using the International Society on Thrombosis and Haemostasis DIC Diagnostic Criteria. The classic picture is a prolonged prothrombin time and activated partial thromboplastin time, low platelets, low fibrinogen and elevated D-dimer test. Management involves addressing the obstetric cause and supportive therapy. Conclusion DIC occurs secondary to a trigger which stimulates the release of procoagulant substances resulting in activation of the clotting pathway. The hypercoagulable state in pregnancy increases the vulnerability of pregnant women. This is a rare case of rapid onset DIC in the second trimester with an ongoing pregnancy.

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