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"Lawrence, Tim"
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Intravenous Iron Therapy in Patients with Iron Deficiency Anemia: Dosing Considerations
Objective. To provide clinicians with evidence-based guidance for iron therapy dosing in patients with iron deficiency anemia (IDA), we conducted a study examining the benefits of a higher cumulative dose of intravenous (IV) iron than what is typically administered. Methods. We first individually analyzed 5 clinical studies, averaging the total iron deficit across all patients utilizing a modified Ganzoni formula; we then similarly analyzed 2 larger clinical studies. For the second of the larger studies (Study 7), we also compared the efficacy and retreatment requirements of a cumulative dose of 1500 mg ferric carboxymaltose (FCM) to 1000 mg iron sucrose (IS). Results. The average iron deficit was calculated to be 1531 mg for patients in Studies 1–5 and 1392 mg for patients in Studies 6-7. The percentage of patients who were retreated with IV iron between Days 56 and 90 was significantly (p<0.001) lower (5.6%) in the 1500 mg group, compared to the 1000 mg group (11.1%). Conclusions. Our data suggests that a total cumulative dose of 1000 mg of IV iron may be insufficient for iron repletion in a majority of patients with IDA and a dose of 1500 mg is closer to the actual iron deficit in these patients.
Journal Article
Specialist healthcare services for concussion/mild traumatic brain injury in England: a consensus statement using modified Delphi methodology
ObjectiveTo establish a consensus on the structure and process of healthcare services for patients with concussion in England to facilitate better healthcare quality and patient outcome.DesignThis consensus study followed the modified Delphi methodology with five phases: participant identification, item development, two rounds of voting and a meeting to finalise the consensus statements. The predefined threshold for agreement was set at ≥70%.SettingSpecialist outpatient services.ParticipantsMembers of the UK Head Injury Network were invited to participate. The network consists of clinical specialists in head injury practising in emergency medicine, neurology, neuropsychology, neurosurgery, paediatric medicine, rehabilitation medicine and sports and exercise medicine in England.Primary outcome measureA consensus statement on the structure and process of specialist outpatient care for patients with concussion in England.Results55 items were voted on in the first round. 29 items were removed following the first voting round and 3 items were removed following the second voting round. Items were modified where appropriate. A final 18 statements reached consensus covering 3 main topics in specialist healthcare services for concussion; care pathway to structured follow-up, prognosis and measures of recovery, and provision of outpatient clinics.ConclusionsThis work presents statements on how the healthcare services for patients with concussion in England could be redesigned to meet their health needs. Future work will seek to implement these into the clinical pathway.
Journal Article
A Machine Learning Enhanced Mechanistic Simulation Framework for Functional Deficit Prediction in TBI
Resting state functional magnetic resonance imaging (rsfMRI), and the underlying brain networks identified with it, have recently appeared as a promising avenue for the evaluation of functional deficits without the need for active patient participation. We hypothesize here that such alteration can be inferred from tissue damage within the network. From an engineering perspective, the numerical prediction of tissue mechanical damage following an impact remains computationally expensive. To this end, we propose a numerical framework aimed at predicting resting state network disruption for an arbitrary head impact, as described by the head velocity, location and angle of impact, and impactor shape. The proposed method uses a library of precalculated cases leveraged by a machine learning layer for efficient and quick prediction. The accuracy of the machine learning layer is illustrated with a dummy fall case, where the machine learning prediction is shown to closely match the full simulation results. The resulting framework is finally tested against the rsfMRI data of nine TBI patients scanned within 24 h of injury, for which paramedical information was used to reconstruct in silico the accident. While more clinical data are required for full validation, this approach opens the door to (i) on-the-fly prediction of rsfMRI alterations, readily measurable on clinical premises from paramedical data, and (ii) reverse-engineered accident reconstruction through rsfMRI measurements.
Journal Article
The next chapter in patient blood management: real-time clinical decision support
Blood transfusion was identified by the American Medical Association as one of the top five most frequently overused therapies. Utilization review has been required by accreditation agencies, but retrospective review has been ineffective due to labor-intense resources applied to only a sampling of transfusion events. Electronic medical records have allowed clinical decision support (CDS) to occur via a best practices alert at the critical decision point concurrently with physician order entry.
We review emerging strategies for improving blood utilization.
Implementation of CDS at our institution decreased the percentage of transfusions in patients with a hemoglobin level of more than 8 g/dL from 60% to less than 30%. Annual RBC transfusions were reduced by 24%, despite concurrent increases in patient discharge volumes and case mix complexity. This resulted in acquisition costs savings (direct blood product purchase costs) of $6.4 million over 4 years.
We have been able to significantly reduce inappropriate blood transfusions and related costs through an educational initiative coupled with real-time CDS. In deriving increased value out of health care, CDS can be applied to a number of overuse measures in laboratory testing, radiology, and therapy such as antibiotics, as outlined by the American Board of Internal Medicine's Choosing Wisely campaign.
Journal Article
Hold on to your dreams : Arthur Russell and the downtown music scene, 1973-1992
Hold On to Your Dreams is the first biography of the musician and composer Arthur Russell, one of the most important but least known contributors to New York's downtown music scene during the 1970s and 1980s. With the exception of a few dance recordings, including \"Is It All Over My Face?\" and \"Go Bang! #5,\" Russell's pioneering music was largely forgotten until 2004, when the posthumous release of two albums brought new attention to the artist. This revival of interest gained momentum with the issue of additional albums and the documentary film Wild Combination. Based on interviews with more than seventy of his collaborators, family members, and friends, Hold On to Your Dreams provides vital new information about this singular, eccentric musician and his role in the boundary-breaking downtown music scene.Tim Lawrence traces Russell's odyssey from his hometown of Oskaloosa, Iowa, to countercultural San Francisco, and eventually to New York, where he lived from 1973 until his death from AIDS-related complications in 1992. Resisting definition while dreaming of commercial success, Russell wrote and performed new wave and disco as well as quirky rock, twisted folk, voice-cello dub, and hip-hop-inflected pop. \"He was way ahead of other people in understanding that the walls between concert music and popular music and avant-garde music were illusory,\" comments the composer Philip Glass. \"He lived in a world in which those walls weren't there.\" Lawrence follows Russell across musical genres and through such vital downtown music spaces as the Kitchen, the Loft, the Gallery, the Paradise Garage, and the Experimental Intermedia Foundation. Along the way, he captures Russell's openness to sound, his commitment to collaboration, and his uncompromising idealism.
eBook
Knowledge of blood loss at delivery among postpartum patients
Postpartum hemorrhage (PPH) is a leading cause of obstetric morbidity. There is limited understanding of patients' knowledge about blood loss at delivery, PPH, and PPH-related morbidities, including transfusion and anemia.
We surveyed 100 healthy postpartum patients who underwent vaginal or cesarean delivery about blood loss, and whether they received information about transfusion and peripartum hemoglobin (Hb) testing. Responses were compared between women undergoing vaginal delivery vs. cesarean delivery; P < 0.05 considered as statistically significant.
In our cohort, 49 women underwent vaginal delivery and 51 women underwent cesarean delivery. Only 29 (29%) of women provided blood loss estimates for their delivery. Women who underwent cesarean delivery were more likely to receive clear information about transfusion therapy than those undergoing vaginal delivery (43.1% vs. 20.4% respectively; P = 0.04). Women who underwent vaginal delivery were more likely to receive results of postpartum Hb tests compared to those undergoing cesarean delivery (49% vs. 29.4%; P = 0.02).
Our findings suggest that women are poorly informed about the magnitude of blood loss at delivery. Hematologic information given to patients varies according to mode of delivery. Further research is needed to better understand the clinical implications of patients' knowledge gaps about PPH, transfusion and postpartum anemia.
Journal Article
Representation, Relation and 'Empêchement': Aesthetic Affinities in Beckett's Dialogues with Georges Duthuit
This essay examines Samuel Beckett's correspondence with Georges Duthuit between 1948 and 1950, the period when Duthuit edited
Transition
with Beckett's close involvement. By contrast to most discussions of Beckett's relationship with Duthuit, the essay focuses on Duthuit's perspective in these exchanges. It argues that Duthuit's assimilation of philosophical perspectives, especially those given in Maurice Merleau-Ponty's
Phénomenologie de la perception
and Maurice Blanchot's
Thomas l'obscur
, were influential for Beckett's own thinking about aesthetics. This thinking is present in
Three Dialogues with Georges Duthuit
(1949), which I argue draws on Duthuit's side of the exchanges more positively than is typically assumed, and I trace how Duthuit's letters to Beckett actively respond to a theory of 'empêchement' - a resistance to representation - expressed in Beckett's earlier art criticism. Moreover, the essay argues that Duthuit's monograph
Les Fauves
, and its translation as
The Fauvist Painters
supervised by Beckett, bear the traces of Duthuit's exchanges with Beckett, and foreshadow the particularity of Beckett's visual aesthetic in mature prose such as
L'Innommable
. In this essay, I therefore add to the material challenging the 'siege in the room' narrative of Beckett as an isolated writer during the post-war period, and also suggest that translation, criticism and correspondence offered a way for both men to work through and engage with specific philosophical ideas subtly present in Beckett's post-war writing.
Journal Article