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Safety and tolerability of iopromide in patients undergoing cardiac catheterization: real-world multicenter experience with 17,513 patients from the TRUST trial. Int J Cardiovasc Imaging 2015; 31:1281-91. [DOI: 10.1007/s10554-015-0688-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 06/01/2015] [Indexed: 01/06/2023]
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Machado GC, Ferreira PH, Harris IA, Pinheiro MB, Koes BW, van Tulder M, Rzewuska M, Maher CG, Ferreira ML. Effectiveness of surgery for lumbar spinal stenosis: a systematic review and meta-analysis. PLoS One 2015; 10:e0122800. [PMID: 25822730 PMCID: PMC4378944 DOI: 10.1371/journal.pone.0122800] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 02/13/2015] [Indexed: 12/31/2022] Open
Abstract
Background The management of spinal stenosis by surgery has increased rapidly in the past two decades, however, there is still controversy regarding the efficacy of surgery for this condition. Our aim was to investigate the efficacy and comparative effectiveness of surgery in the management of patients with lumbar spinal stenosis. Methods Electronic searches were performed on MEDLINE, EMBASE, AMED, CINAHL, Web of Science, LILACS and Cochrane Library from inception to November 2014. Hand searches were conducted on included articles and relevant reviews. We included randomised controlled trials evaluating surgery compared to no treatment, placebo/sham, or to another surgical technique in patients with lumbar spinal stenosis. Primary outcome measures were pain, disability, recovery and quality of life. The PEDro scale was used for risk of bias assessment. Data were pooled with a random-effects model, and the GRADE approach was used to summarise conclusions. Results Nineteen published reports (17 trials) were included. No trials were identified comparing surgery to no treatment or placebo/sham. Pooling revealed that decompression plus fusion is not superior to decompression alone for pain (mean difference –3.7, 95% confidence interval –15.6 to 8.1), disability (mean difference 9.8, 95% confidence interval –9.4 to 28.9), or walking ability (risk ratio 0.9, 95% confidence interval 0.4 to 1.9). Interspinous process spacer devices are slightly more effective than decompression plus fusion for disability (mean difference 5.7, 95% confidence interval 1.3 to 10.0), but they resulted in significantly higher reoperation rates when compared to decompression alone (28% v 7%, P < 0.001). There are no differences in the effectiveness between other surgical techniques for our main outcomes. Conclusions The relative efficacy of various surgical options for treatment of spinal stenosis remains uncertain. Decompression plus fusion is not more effective than decompression alone. Interspinous process spacer devices result in higher reoperation rates than bony decompression.
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Affiliation(s)
- Gustavo C. Machado
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- * E-mail:
| | - Paulo H. Ferreira
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Ian A. Harris
- South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, University of New South Wales, Sydney, NSW, Australia
| | - Marina B. Pinheiro
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Bart W. Koes
- Department of General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Maurits van Tulder
- Department of Health Sciences, VU University, Amsterdam, The Netherlands
| | - Magdalena Rzewuska
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Chris G. Maher
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Manuela L. Ferreira
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Institute of Bone and Joint Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Adverse event reporting in nonpharmacologic, noninterventional pain clinical trials: ACTTION systematic review. Pain 2014; 155:2253-62. [DOI: 10.1016/j.pain.2014.08.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 07/30/2014] [Accepted: 08/06/2014] [Indexed: 11/19/2022]
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Inclusion of quasi-experimental studies in systematic reviews of health systems research. Health Policy 2014; 119:511-21. [PMID: 25776033 DOI: 10.1016/j.healthpol.2014.10.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 09/29/2014] [Accepted: 10/11/2014] [Indexed: 12/30/2022]
Abstract
Systematic reviews of health systems research commonly limit studies for evidence synthesis to randomized controlled trials. However, well-conducted quasi-experimental studies can provide strong evidence for causal inference. With this article, we aim to stimulate and inform discussions on including quasi-experiments in systematic reviews of health systems research. We define quasi-experimental studies as those that estimate causal effect sizes using exogenous variation in the exposure of interest that is not directly controlled by the researcher. We incorporate this definition into a non-hierarchical three-class taxonomy of study designs - experiments, quasi-experiments, and non-experiments. Based on a review of practice in three disciplines related to health systems research (epidemiology, economics, and political science), we discuss five commonly used study designs that fit our definition of quasi-experiments: natural experiments, instrumental variable analyses, regression discontinuity analyses, interrupted times series studies, and difference studies including controlled before-and-after designs, difference-in-difference designs and fixed effects analyses of panel data. We further review current practices regarding quasi-experimental studies in three non-health fields that utilize systematic reviews (education, development, and environment studies) to inform the design of approaches for synthesizing quasi-experimental evidence in health systems research. Ultimately, the aim of any review is practical: to provide useful information for policymakers, practitioners, and researchers. Future work should focus on building a consensus among users and producers of systematic reviews regarding the inclusion of quasi-experiments.
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Adverse events among seniors receiving spinal manipulation and exercise in a randomized clinical trial. ACTA ACUST UNITED AC 2014; 20:335-41. [PMID: 25454683 DOI: 10.1016/j.math.2014.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 09/29/2014] [Accepted: 10/07/2014] [Indexed: 12/16/2022]
Abstract
Spinal manipulative therapy (SMT) and exercise have demonstrated effectiveness for neck pain (NP). Adverse events (AE) reporting in trials, particularly among elderly participants, is inconsistent and challenges informed clinical decision making. This paper provides a detailed report of AE experienced by elderly participants in a randomized comparative effectiveness trial of SMT and exercise for chronic NP. AE data, consistent with CONSORT recommendations, were collected on elderly participants who received 12 weeks of SMT with home exercise, supervised plus home exercise, or home exercise alone. Standardized questions were asked at each treatment; participants were additionally encouraged to report AE as they occurred. Qualitative interviews documented participants' experiences with AE. Descriptive statistics and content analysis were used to categorize and report these data. Compliance was high among the 241 randomized participants. Non-serious AE were reported by 130/194 participants. AE were reported by three times as many participants in supervised plus home exercise, and nearly twice as many as in SMT with home exercise, as in home exercise alone. The majority of AE were musculoskeletal in nature; several participants associated AE with specific exercises. One incapacitating AE occurred when a participant fell during supervised exercise session and fractured their arm. One serious adverse event of unknown relationship occurred to an individual who died from an aneurysm while at home. Eight serious, non-related AE also occurred. Musculoskeletal AE were common among elderly participants receiving SMT and exercise interventions for NP. As such, they should be expected and discussed when developing care plans.
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Bias and small-study effects influence treatment effect estimates: a meta-epidemiological study in oral medicine. J Clin Epidemiol 2014; 67:984-92. [DOI: 10.1016/j.jclinepi.2014.04.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 04/01/2014] [Accepted: 04/04/2014] [Indexed: 12/17/2022]
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Osimani B. Safety vs. efficacy assessment of pharmaceuticals: Epistemological rationales and methods. Prev Med Rep 2014; 1:9-13. [PMID: 26844033 PMCID: PMC4721437 DOI: 10.1016/j.pmedr.2014.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
In their comparative analysis of Randomised Clinical Trials and observational studies, Papanikoloau et al. (2006) assert that "it may be unfair to invoke bias and confounding to discredit observational studies as a source of evidence on harms". There are two kinds of answers to the question why this is so. One is based on metaphysical assumptions, such as the problem of causal sufficiency, modularity and other statistical assumptions. The other is epistemological and relates to foundational issues and how they determine the constraints we put on evidence. I will address here the latter dimension and present recent proposals to amend evidence hierarchies for the purpose of safety assessment of pharmaceuticals; I then relate these suggestions to a case study: the recent debate on the causal association between paracetamol and asthma. The upshot of this analysis is that different epistemologies impose different constraints on the methods we adopt to collect and evaluate evidence; thus they grant "lower level" evidence on distinct grounds and at different conditions. Appreciating this state of affairs illuminates the debate on the epistemic asymmetry concerning benefits and harms and sets the basis for a foundational, as opposed to heuristic, justification of safety assessment based on heterogeneous evidence.
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Affiliation(s)
- Barbara Osimani
- University of Camerino, School of Pharmacology, P.zza dei Costanti, 62032 Camerino, Italy
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Development and validation of providers’ and patients’ measurement instruments to evaluate adverse events after spinal manipulation therapy. Eur J Integr Med 2014. [DOI: 10.1016/j.eujim.2014.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg 2014; 12:1495-9. [PMID: 25046131 DOI: 10.1016/j.ijsu.2014.07.013] [Citation(s) in RCA: 5628] [Impact Index Per Article: 562.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available on the Web sites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.
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Affiliation(s)
- Erik von Elm
- Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, IUMSP - Institut universitaire de médecine sociale et préventive, Lausanne, Switzerland.
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland; Centre for Infectious Diseases Epidemiology and Research (CIDER), University of Cape Town, South Africa
| | - Stuart J Pocock
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | | | - Jan P Vandenbroucke
- Department of Clinical Epidemiology, Leiden University Hospital, Leiden, The Netherlands
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Identifying Predictors of Unacceptable Pain at Office Hysteroscopy. J Minim Invasive Gynecol 2014; 21:586-91. [DOI: 10.1016/j.jmig.2013.12.118] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 12/02/2013] [Accepted: 12/16/2013] [Indexed: 11/21/2022]
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Riaz N, Hong JC, Sherman EJ, Morris L, Fury M, Ganly I, Wang TJC, Shi W, Wolden SL, Jackson A, Wong RJ, Zhang Z, Rao SD, Lee NY. A nomogram to predict loco-regional control after re-irradiation for head and neck cancer. Radiother Oncol 2014; 111:382-7. [PMID: 24993329 DOI: 10.1016/j.radonc.2014.06.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 05/26/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE Loco-regionally recurrent head and neck cancer (HNC) in the setting of prior radiotherapy carries significant morbidity and mortality. The role of re-irradiation (re-RT) remains unclear due to toxicity. We determined prognostic factors for loco-regional control (LRC) and formulated a nomogram to help clinicians select re-RT candidates. MATERIAL AND METHODS From July 1996 to April 2011, 257 patients with recurrent HNC underwent fractionated re-RT. Median prior dose was 65 Gy and median time between RT was 32.4 months. One hundred fifteen patients (44%) had salvage surgery and 172 (67%) received concurrent chemotherapy. Median re-RT dose was 59.4 Gy and 201 (78%) patients received IMRT. Multivariate Cox proportional hazards were used to identify independent predictors of LRC and a nomogram for 2-year LRC was constructed. RESULTS Median follow-up was 32.6 months. Two-year LRC and overall survival (OS) were 47% and 43%, respectively. Recurrent stage (P=0.005), non-oral cavity subsite (P<0.001), absent organ dysfunction (P<0.001), salvage surgery (P<0.001), and dose >50 Gy (P=0.006) were independently associated with improved LRC. We generated a nomogram with concordance index of 0.68. CONCLUSION Re-RT can be curative, and our nomogram can help determine a priori which patients may benefit.
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Affiliation(s)
- Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Julian C Hong
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Eric J Sherman
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Luc Morris
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Matthew Fury
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Ian Ganly
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Tony J C Wang
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Weji Shi
- Department of Radiation Oncology, Columbia University, New York, United States
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Andrew Jackson
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Richard J Wong
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Zhigang Zhang
- Department of Radiation Oncology, Columbia University, New York, United States
| | - Shyam D Rao
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, United States
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, United States.
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Balloon brachytherapy for breast cancer prove that it works? Or, prove that it doesn't? J Cancer Res Clin Oncol 2014; 140:1353-7. [PMID: 24858568 DOI: 10.1007/s00432-014-1705-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 05/05/2014] [Indexed: 10/25/2022]
Abstract
Balloon breast brachytherapy is a catheter-based technique to deliver high local concentration of radiation following breast-sparing surgery. Although this technique is logically appealing--providing more directed radiation to sites at high risk of local failure--there remains little empirical support that this intervention is non-inferior to external beam radiotherapy, a well-established standard. Additionally, observational studies suggest that balloon brachytherapy is associated with high rates of local complications, and higher rates of subsequent mastectomy, a marker of local failure. Here, I explore regulatory and clinical considerations that lead to the widespread adoption of breast brachytherapy. I argue that the therapy spread before its efficacy was confirmed. Breast brachytherapy illustrates ongoing complexities in the approval of novel devices.
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Anglemyer A, Horvath HT, Bero L. Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials. Cochrane Database Syst Rev 2014; 2014:MR000034. [PMID: 24782322 PMCID: PMC8191367 DOI: 10.1002/14651858.mr000034.pub2] [Citation(s) in RCA: 229] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Researchers and organizations often use evidence from randomized controlled trials (RCTs) to determine the efficacy of a treatment or intervention under ideal conditions. Studies of observational designs are often used to measure the effectiveness of an intervention in 'real world' scenarios. Numerous study designs and modifications of existing designs, including both randomized and observational, are used for comparative effectiveness research in an attempt to give an unbiased estimate of whether one treatment is more effective or safer than another for a particular population.A systematic analysis of study design features, risk of bias, parameter interpretation, and effect size for all types of randomized and non-experimental observational studies is needed to identify specific differences in design types and potential biases. This review summarizes the results of methodological reviews that compare the outcomes of observational studies with randomized trials addressing the same question, as well as methodological reviews that compare the outcomes of different types of observational studies. OBJECTIVES To assess the impact of study design (including RCTs versus observational study designs) on the effect measures estimated.To explore methodological variables that might explain any differences identified.To identify gaps in the existing research comparing study designs. SEARCH METHODS We searched seven electronic databases, from January 1990 to December 2013.Along with MeSH terms and relevant keywords, we used the sensitivity-specificity balanced version of a validated strategy to identify reviews in PubMed, augmented with one term ("review" in article titles) so that it better targeted narrative reviews. No language restrictions were applied. SELECTION CRITERIA We examined systematic reviews that were designed as methodological reviews to compare quantitative effect size estimates measuring efficacy or effectiveness of interventions tested in trials with those tested in observational studies. Comparisons included RCTs versus observational studies (including retrospective cohorts, prospective cohorts, case-control designs, and cross-sectional designs). Reviews were not eligible if they compared randomized trials with other studies that had used some form of concurrent allocation. DATA COLLECTION AND ANALYSIS In general, outcome measures included relative risks or rate ratios (RR), odds ratios (OR), hazard ratios (HR). Using results from observational studies as the reference group, we examined the published estimates to see whether there was a relative larger or smaller effect in the ratio of odds ratios (ROR).Within each identified review, if an estimate comparing results from observational studies with RCTs was not provided, we pooled the estimates for observational studies and RCTs. Then, we estimated the ratio of ratios (risk ratio or odds ratio) for each identified review using observational studies as the reference category. Across all reviews, we synthesized these ratios to get a pooled ROR comparing results from RCTs with results from observational studies. MAIN RESULTS Our initial search yielded 4406 unique references. Fifteen reviews met our inclusion criteria; 14 of which were included in the quantitative analysis.The included reviews analyzed data from 1583 meta-analyses that covered 228 different medical conditions. The mean number of included studies per paper was 178 (range 19 to 530).Eleven (73%) reviews had low risk of bias for explicit criteria for study selection, nine (60%) were low risk of bias for investigators' agreement for study selection, five (33%) included a complete sample of studies, seven (47%) assessed the risk of bias of their included studies,Seven (47%) reviews controlled for methodological differences between studies,Eight (53%) reviews controlled for heterogeneity among studies, nine (60%) analyzed similar outcome measures, and four (27%) were judged to be at low risk of reporting bias.Our primary quantitative analysis, including 14 reviews, showed that the pooled ROR comparing effects from RCTs with effects from observational studies was 1.08 (95% confidence interval (CI) 0.96 to 1.22). Of 14 reviews included in this analysis, 11 (79%) found no significant difference between observational studies and RCTs. One review suggested observational studies had larger effects of interest, and two reviews suggested observational studies had smaller effects of interest.Similar to the effect across all included reviews, effects from reviews comparing RCTs with cohort studies had a pooled ROR of 1.04 (95% CI 0.89 to 1.21), with substantial heterogeneity (I(2) = 68%). Three reviews compared effects of RCTs and case-control designs (pooled ROR: 1.11 (95% CI 0.91 to 1.35)).No significant difference in point estimates across heterogeneity, pharmacological intervention, or propensity score adjustment subgroups were noted. No reviews had compared RCTs with observational studies that used two of the most common causal inference methods, instrumental variables and marginal structural models. AUTHORS' CONCLUSIONS Our results across all reviews (pooled ROR 1.08) are very similar to results reported by similarly conducted reviews. As such, we have reached similar conclusions; on average, there is little evidence for significant effect estimate differences between observational studies and RCTs, regardless of specific observational study design, heterogeneity, or inclusion of studies of pharmacological interventions. Factors other than study design per se need to be considered when exploring reasons for a lack of agreement between results of RCTs and observational studies. Our results underscore that it is important for review authors to consider not only study design, but the level of heterogeneity in meta-analyses of RCTs or observational studies. A better understanding of how these factors influence study effects might yield estimates reflective of true effectiveness.
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Affiliation(s)
- Andrew Anglemyer
- University of California, San FranciscoGlobal Health SciencesSan FranciscoCaliforniaUSA94105
| | - Hacsi T Horvath
- University of California, San FranciscoGlobal Health SciencesSan FranciscoCaliforniaUSA94105
| | - Lisa Bero
- University of California San FranciscoDepartment of Clinical Pharmacy and Institute for Health Policy StudiesSuite 420, Box 06133333 California StreetSan FranciscoCaliforniaUSA94143‐0613
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Drug-safety alerts issued by regulatory authorities: usefulness of meta-analysis in predicting risks earlier. Eur J Clin Pharmacol 2014; 70:745-56. [DOI: 10.1007/s00228-014-1670-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 03/18/2014] [Indexed: 11/26/2022]
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Comparison of treatment effect estimates from prospective nonrandomized studies with propensity score analysis and randomized controlled trials of surgical procedures. Ann Surg 2014; 259:18-25. [PMID: 24096758 DOI: 10.1097/sla.0000000000000256] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We aimed to compare treatment effect estimates from NRSs with PS analysis and RCTs of surgery. BACKGROUND Evaluating a surgical procedure in randomized controlled trials (RCTs) is challenging. Nonrandomized studies (NRSs) involving use of propensity score (PS) analysis to limit bias are of increasing interest. DESIGN Meta-epidemiological study. METHODS We systematically searched MEDLINE via PubMed for all prospective NRSs with PS analysis evaluating a surgical procedure. Related RCTs, addressing the same clinical questions, were systematically retrieved. Our primary outcome of interest was all-cause mortality. We also selected 1 subjective outcome. We calculated the summary odds ratios (OR) for each study design, the ratio of OR (ROR) between the designs and the summary ROR across clinical questions. An ROR<1 indicated that the experimental intervention is more favorable in NRSs with PS analysis than RCTs. RESULTS We retrieved 70 reports of NRSs with PS analysis and 94 related RCTs evaluating 31 clinical questions, of which 22 assessed all-cause mortality and 26 a subjective outcome. The combined ROR for all-cause mortality was 0.83 (95% confidence interval: 0.65-1.04). For subjective outcomes, the combined ROR was 1.07 (0.87-1.33). CONCLUSIONS There was no statistically significant difference in treatment effect between NRSs with PS analysis and RCTs. Prospective NRSs with suitable and careful PS analysis can be relied upon as evidence when RCTs are not possible.
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Tamini N, Rota M, Bolzonaro E, Nespoli L, Nespoli A, Valsecchi MG, Gianotti L. Single-incision versus standard multiple-incision laparoscopic cholecystectomy: a meta-analysis of experimental and observational studies. Surg Innov 2014; 21:528-45. [PMID: 24608182 DOI: 10.1177/1553350614521017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The advantages of single-incision surgery for the treatment of gallstone disease is debated. Previous meta-analyses comparing single-incision laparoscopic cholecystectomy (SILC) and standard laparoscopic multiport cholecystectomy (SLMC) included few and underpowered trials. To overcome this limitation, we performed a meta-analysis of randomized and nonrandomized studies. METHODS A MEDLINE, EMBASE, and Cochrane Library literature search of studies published in and comparing SILC with SLMC was performed. The primary outcome was safety of SILC as measured by the overall rate of postoperative complications and biliary spillage. Feasibility was another primary outcome as measured by the conversion and operative time. Postoperative pain, length of hospital stay, perioperative blood loss, time to return to normal activity, and cosmetic satisfaction were secondary outcomes. RESULTS We identified 43 studies of which 30 were observational reports and 13 experimental trials, for a total of 7489 patients (2090 SILC and 5389 SLMC). The overall rate of complications was comparable between groups (relative risk [RR] = 1.08; 95% CI = 0.87-1.35; P = .46), as were the rates of biliary spillage (RR = 1.16; 95% CI = 0.73-1.84; P = .53) and conversion rate (RR = 0.88; 95% CI = 0.53-1.46; P = .62). Operative time was in favor of SLMC (weighted mean difference = 0.73; 95% CI = 0.67-0.79; P < .0001). Secondary outcomes favored SILC, but with marginal advantages. CONCLUSIONS SILC is a feasible technique but without any significant advantage over SLMC for relevant end points. Although secondary outcomes favored SILC, the small magnitude of the advantage and the low quality of assessment methods question the clinical significance of these benefits.
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Affiliation(s)
- Nicolò Tamini
- Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Matteo Rota
- Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Elisa Bolzonaro
- Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Luca Nespoli
- Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Angelo Nespoli
- Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | | | - Luca Gianotti
- Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
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Peinemann F, Tushabe DA, Kleijnen J. Using multiple types of studies in systematic reviews of health care interventions--a systematic review. PLoS One 2013; 8:e85035. [PMID: 24416098 PMCID: PMC3887134 DOI: 10.1371/journal.pone.0085035] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 11/23/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A systematic review may evaluate different aspects of a health care intervention. To accommodate the evaluation of various research questions, the inclusion of more than one study design may be necessary. One aim of this study is to find and describe articles on methodological issues concerning the incorporation of multiple types of study designs in systematic reviews on health care interventions. Another aim is to evaluate methods studies that have assessed whether reported effects differ by study types. METHODS AND FINDINGS We searched PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Methodology Register on 31 March 2012 and identified 42 articles that reported on the integration of single or multiple study designs in systematic reviews. We summarized the contents of the articles qualitatively and assessed theoretical and empirical evidence. We found that many examples of reviews incorporating multiple types of studies exist and that every study design can serve a specific purpose. The clinical questions of a systematic review determine the types of design that are necessary or sufficient to provide the best possible answers. In a second independent search, we identified 49 studies, 31 systematic reviews and 18 trials that compared the effect sizes between randomized and nonrandomized controlled trials, which were statistically different in 35%, and not different in 53%. Twelve percent of studies reported both, different and non-different effect sizes. CONCLUSIONS Different study designs addressing the same question yielded varying results, with differences in about half of all examples. The risk of presenting uncertain results without knowing for sure the direction and magnitude of the effect holds true for both nonrandomized and randomized controlled trials. The integration of multiple study designs in systematic reviews is required if patients should be informed on the many facets of patient relevant issues of health care interventions.
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Affiliation(s)
- Frank Peinemann
- University of Maastricht, School for Public Health and Primary Care, Maastricht, The Netherlands
- Children's Hospital, University of Cologne, Cologne, Germany
- * E-mail:
| | - Doreen Allen Tushabe
- University of Birmingham, Department of Public Health, Epidemiology & Biostatistics, Birmingham, United Kingdom
| | - Jos Kleijnen
- University of Maastricht, School for Public Health and Primary Care, Maastricht, The Netherlands
- Kleijnen Systematic Reviews Ltd, York, United Kingdom
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Van Vugt R, Keus F, Kool D, Deunk J, Edwards M. Selective computed tomography (CT) versus routine thoracoabdominal CT for high-energy blunt-trauma patients. Cochrane Database Syst Rev 2013; 2013:CD009743. [PMID: 24363034 PMCID: PMC6464744 DOI: 10.1002/14651858.cd009743.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Trauma is the fifth leading cause of death worldwide, and in people younger than 40 years of age, it is the leading cause of death. During the resuscitation of trauma patients at the emergency department, there are two different commonly used diagnostic strategies. Conventionally, there is the use of physical examination and conventional diagnostic imaging, potentially followed by selective use of computed tomography (CT). Alternatively, there is the use of physical examination and conventional diagnostics, followed by a routine (instead of selective) use of thoracoabdominal CT. It is currently unknown which of the two strategies is the better diagnostic strategy for patients with blunt high-energy trauma. OBJECTIVES To assess the effects of routine thoracoabdominal CT compared with selective thoracoabdominal CT on mortality in blunt high-energy trauma patients. SEARCH METHODS We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (Issue 4, 2013); MEDLINE (OvidSP), EMBASE (OvidSP) and CINAHL for all published randomised controlled trials (RCTs). We did not restrict the searches by language, date or publication status. We conducted the search on the 9 May 2013. SELECTION CRITERIA We included RCTs of trauma resuscitation algorithms using routine thoracoabdominal CT versus algorithms using selective CT in this review. We included all blunt high-energy trauma patients (including blast or barotrauma). DATA COLLECTION AND ANALYSIS Two authors independently evaluated the search results. MAIN RESULTS The systematic search identified 481 references; after removal of duplicates, 396 remained. We found no RCTs comparing routine versus selective thoracoabdominal CT in blunt high-energy trauma patients. We excluded 381 studies based on the abstracts of the publications because of irrelevance to the review topic, and a further 15 studies after full-text evaluation. AUTHORS' CONCLUSIONS We found no RCTs of routine versus selective thoracoabdominal CT in patients with blunt high-energy trauma. Based on the lack of evidence from RCTs, it is not possible to say which approach is better in reducing deaths.
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Affiliation(s)
- Raoul Van Vugt
- Radboud University Nijmegen Medical CenterDepartment of Surgery and TraumaPO Box 9101NijmegenNetherlands6500 HB
| | - Frederik Keus
- University of Groningen, University Medical Center GroningenDepartment of Critical CareHanzeplein 1GroningenNetherlands9713 GZ
| | - Digna Kool
- Canisius Wilhelmina HospitalDepartment of RadiologyPO Box 9101NijmegenNetherlands6500 HB
| | - Jaap Deunk
- VU Medical CenterDepartment of SurgeryDe Run 4600AmsterdamNetherlands5504
| | - Michael Edwards
- Radboud University Nijmegen Medical CenterDepartment of Surgery and TraumaPO Box 9101NijmegenNetherlands6500 HB
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Carling CLL, Kirkehei I, Dalsbø TK, Paulsen E. Risks to patient safety associated with implementation of electronic applications for medication management in ambulatory care--a systematic review. BMC Med Inform Decis Mak 2013; 13:133. [PMID: 24308799 PMCID: PMC3913838 DOI: 10.1186/1472-6947-13-133] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 11/26/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The objective was to find evidence to substantiate assertions that electronic applications for medication management in ambulatory care (electronic prescribing, clinical decision support (CDSS), electronic health record, and computer generated paper prescriptions), while intended to reduce prescribing errors, can themselves result in errors that might harm patients or increase risks to patient safety. METHODS Because a scoping search for adverse events in randomized controlled trials (RCTs) yielded few relevant results, we systematically searched nine databases, including MEDLINE, EMBASE, and The Cochrane Database of Systematic Reviews for systematic reviews and studies of a wide variety of designs that reported on implementation of the interventions. Studies that had safety and adverse events as outcomes, monitored for them, reported anecdotally adverse events or other events that might indicate a threat to patient safety were included. RESULTS We found no systematic reviews that examined adverse events or patient harm caused by organizational interventions. Of the 4056 titles and abstracts screened, 176 full-text articles were assessed for inclusion. Sixty-one studies with appropriate interventions, settings and participants but without patient safety, adverse event outcomes or monitoring for risks were excluded, along with 77 other non-eligible studies. Eighteen randomized controlled trials (RCTs), 5 non-randomized controlled trials (non-R,CTs) and 15 observational studies were included. The most common electronic intervention studied was CDSS and the most frequent clinical area was cardio-vascular, including anti-coagulants. No RCTS or non-R,CTS reported adverse event. Adverse events reported in observational studies occurred less frequently after implementation of CDSS. One RCT and one observational study reported an increase in problematic prescriptions with electronic prescribing CONCLUSIONS The safety implications of electronic medication management in ambulatory care have not been established with results from studies included in this systematic review. Only a minority of studies that investigated these interventions included threats to patients' safety as outcomes or monitored for adverse events. It is therefore not surprising that we found little evidence to substantiate fears of new risks to patient safety with their implementation. More research is needed to focus on the draw-backs and negative outcomes that implementation of these interventions might introduce.
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Affiliation(s)
- Cheryl LL Carling
- The Norwegian Knowledge Centre for the Health Services, PO Box 7004, St. Olavsplass, 0130 Oslo, Norway
| | - Ingvild Kirkehei
- The Norwegian Knowledge Centre for the Health Services, PO Box 7004, St. Olavsplass, 0130 Oslo, Norway
| | - Therese Kristine Dalsbø
- The Norwegian Knowledge Centre for the Health Services, PO Box 7004, St. Olavsplass, 0130 Oslo, Norway
| | - Elizabeth Paulsen
- The Norwegian Knowledge Centre for the Health Services, PO Box 7004, St. Olavsplass, 0130 Oslo, Norway
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Ioannidis JPA, Zhou Y, Chang CQ, Schully SD, Khoury MJ, Freedman AN. Potential increased risk of cancer from commonly used medications: an umbrella review of meta-analyses. Ann Oncol 2013; 25:16-23. [PMID: 24310915 DOI: 10.1093/annonc/mdt372] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Several commonly used medications have been associated with increased cancer risk in the literature. Here, we evaluated the strength and consistency of these claims in published meta-analyses. We carried out an umbrella review of 74 meta-analysis articles addressing the association of commonly used medications (antidiabetics, antihyperlipidemics, antihypertensives, antirheumatics, drugs for osteoporosis, and others) with cancer risk where at least one meta-analysis in the medication class included some data from randomized trials. Overall, 51 articles found no statistically significant differences, 13 found some decreased cancer risk, and 11 found some increased risk (one reported both increased and decreased risks). The 11 meta-analyses that found some increased risks reported 16 increased risk estimates, of which 5 pertained to overall cancer and 11 to site-specific cancer. Six of the 16 estimates were derived from randomized trials and 10 from observational data. Estimates of increased risk were strongly inversely correlated with the amount of evidence (number of cancer cases) (Spearman's correlation coefficient = -0.77, P < 0.001). In 4 of the 16 topics, another meta-analysis existed that was larger (n = 2) or included better controlled data (n = 2) and in all 4 cases there was no statistically significantly increased risk of malignancy. No medication or class had substantial and consistent evidence for increased risk of malignancy. However, for most medications we cannot exclude small risks or risks in population subsets. Such risks are unlikely to be possible to document robustly unless very large, collaborative studies with standardized analyses and no selective reporting are carried out.
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Affiliation(s)
- J P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine and Department of Health Research and Policy, Stanford University School of Medicine, Stanford
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Bain ES, Middleton PF, Crowther CA. Maternal adverse effects of different antenatal magnesium sulphate regimens for improving maternal and infant outcomes: a systematic review. BMC Pregnancy Childbirth 2013; 13:195. [PMID: 24139447 PMCID: PMC4015216 DOI: 10.1186/1471-2393-13-195] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/16/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antenatal magnesium sulphate, widely used in obstetrics to improve maternal and infant outcomes, may be associated with adverse effects for the mother sufficient for treatment cessation. This systematic review aimed to quantify maternal adverse effects attributed to treatment, assess how adverse effects vary according to different regimens, and explore women's experiences with this treatment. METHODS Bibliographic databases were searched from their inceptions to July 2012 for studies of any design that reported on maternal adverse effects associated with antenatal magnesium sulphate given to improve maternal or infant outcomes. Primary outcomes were life-threatening adverse effects of treatment (death, cardiac arrest, respiratory arrest). For randomised controlled trials, data were meta-analysed, and risk ratios (RR) pooled using fixed-effects or random-effects models. For non-randomised studies, data were tabulated by design, and presented as RR, odds ratios or percentages, and summarised narratively. RESULTS A total of 143 publications were included (21 randomised trials, 15 non-randomised comparative studies, 32 case series and 75 reports of individual cases), of mixed methodological quality. Compared with placebo or no treatment, magnesium sulphate was not associated with an increased risk of maternal death, cardiac arrest or respiratory arrest. Magnesium sulphate significantly increased the risk of 'any adverse effects' overall (RR 4.62, 95% CI 2.42-8.83; 4 trials, 13,322 women), and treatment cessation due to adverse effects (RR 2.77; 95% CI 2.32-3.30; 5 trials, 13,666 women). Few subgroup differences were observed (between indications for use and treatment regimens). In one trial, a lower dose regimen (2 g/3 hours) compared with a higher dose regimen (5 g/4 hours) significantly reduced treatment cessation (RR 0.05; 95% CI 0.01-0.39, 126 women). Adverse effect estimates from studies of other designs largely supported data from randomised trials. Case reports supported an association between iatrogenic overdose of magnesium sulphate and life-threatening consequences. CONCLUSIONS Appropriate administration of antenatal magnesium sulphate was not shown to be associated with serious maternal adverse effects, though an increase in 'minor' adverse effects and treatment cessation was shown. Larger trials are needed to determine optimal regimens, achieving maximal effectiveness with minimal adverse effects, for each antenatal indication for use. Vigilance in the use of magnesium sulphate is essential for women's safety.
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Affiliation(s)
- Emily S Bain
- Australian Research Centre for Health of Women and Babies, Robinson Institute, Discipline of Obstetrics and Gynaecology, School of Paediatrics and Reproductive Health, The University of Adelaide, 72 King William Road, Adelaide, South Australia, Australia
| | - Philippa F Middleton
- Australian Research Centre for Health of Women and Babies, Robinson Institute, Discipline of Obstetrics and Gynaecology, School of Paediatrics and Reproductive Health, The University of Adelaide, 72 King William Road, Adelaide, South Australia, Australia
| | - Caroline A Crowther
- Australian Research Centre for Health of Women and Babies, Robinson Institute, Discipline of Obstetrics and Gynaecology, School of Paediatrics and Reproductive Health, The University of Adelaide, 72 King William Road, Adelaide, South Australia, Australia
- Liggins Institute, The University of Auckland, Auckland, New Zealand
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Wijnhoven BPL, Toxopeus ELA, Vallböhmer D, Knoefel WT, Krasna MJ, Perez K, van Rossum PSN, Ruurda JP, van Hillegersberg R, Schiesser M, Schneider P, Felix VN. New therapeutic strategies for squamous cell cancer and adenocarcinoma. Ann N Y Acad Sci 2013; 1300:213-225. [PMID: 24117644 DOI: 10.1111/nyas.12247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This paper presents commentaries on neoadjuvant treatment esophagectomy; the prognostic and predictive effects of single nucleotide polymorphisms (SNP) in the multimodality therapy of esophageal cancer; optimal preoperative treatment prior to surgery for esophageal cancer; a possible role for trastuzumab in treating esophageal adenocarcinoma or any esophageal dysplasia/intra-epithelial neoplasia; surgery after chemoradiation in resectable esophageal cancer; whether para-aortic lymph node dissection should be performed in esophagogastric junction (EGJ) tumors; and transhiatal esophagectomy in treatment of the esophageal cancer.
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Affiliation(s)
- Bas P L Wijnhoven
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eelke L A Toxopeus
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Daniel Vallböhmer
- Department of General, Visceral and Pediatric Surgery, University of Düsseldorf, Düsseldorf, Germany
| | - Wolfram T Knoefel
- Department of General, Visceral and Pediatric Surgery, University of Düsseldorf, Düsseldorf, Germany
| | - Mark J Krasna
- Jersey Shore University Medical Center, Neptune, New Jersey
| | - Kimberly Perez
- Division of Hematology - Oncology, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Peter S N van Rossum
- Departments of Surgery and Radiotherapy, University Medical Center, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Departments of Surgery and Radiotherapy, University Medical Center, Utrecht, The Netherlands
| | | | - Marc Schiesser
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Paul Schneider
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
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Drug-induced acute myocardial infarction: identifying 'prime suspects' from electronic healthcare records-based surveillance system. PLoS One 2013; 8:e72148. [PMID: 24015213 PMCID: PMC3756064 DOI: 10.1371/journal.pone.0072148] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 07/05/2013] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Drug-related adverse events remain an important cause of morbidity and mortality and impose huge burden on healthcare costs. Routinely collected electronic healthcare data give a good snapshot of how drugs are being used in 'real-world' settings. OBJECTIVE To describe a strategy that identifies potentially drug-induced acute myocardial infarction (AMI) from a large international healthcare data network. METHODS Post-marketing safety surveillance was conducted in seven population-based healthcare databases in three countries (Denmark, Italy, and the Netherlands) using anonymised demographic, clinical, and prescription/dispensing data representing 21,171,291 individuals with 154,474,063 person-years of follow-up in the period 1996-2010. Primary care physicians' medical records and administrative claims containing reimbursements for filled prescriptions, laboratory tests, and hospitalisations were evaluated using a three-tier triage system of detection, filtering, and substantiation that generated a list of drugs potentially associated with AMI. Outcome of interest was statistically significant increased risk of AMI during drug exposure that has not been previously described in current literature and is biologically plausible. RESULTS Overall, 163 drugs were identified to be associated with increased risk of AMI during preliminary screening. Of these, 124 drugs were eliminated after adjustment for possible bias and confounding. With subsequent application of criteria for novelty and biological plausibility, association with AMI remained for nine drugs ('prime suspects'): azithromycin; erythromycin; roxithromycin; metoclopramide; cisapride; domperidone; betamethasone; fluconazole; and megestrol acetate. LIMITATIONS Although global health status, co-morbidities, and time-invariant factors were adjusted for, residual confounding cannot be ruled out. CONCLUSION A strategy to identify potentially drug-induced AMI from electronic healthcare data has been proposed that takes into account not only statistical association, but also public health relevance, novelty, and biological plausibility. Although this strategy needs to be further evaluated using other healthcare data sources, the list of 'prime suspects' makes a good starting point for further clinical, laboratory, and epidemiologic investigation.
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Bastuji-Garin S, Sbidian E, Gaudy-Marqueste C, Ferrat E, Roujeau JC, Richard MA, Canoui-Poitrine F. Impact of STROBE statement publication on quality of observational study reporting: interrupted time series versus before-after analysis. PLoS One 2013; 8:e64733. [PMID: 23990867 PMCID: PMC3753332 DOI: 10.1371/journal.pone.0064733] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 04/17/2013] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In uncontrolled before-after studies, CONSORT was shown to improve the reporting of randomised trials. Before-after studies ignore underlying secular trends and may overestimate the impact of interventions. Our aim was to assess the impact of the 2007 STROBE statement publication on the quality of observational study reporting, using both uncontrolled before-after analyses and interrupted time series. METHODS For this quasi-experimental study, original articles reporting cohort, case-control, and cross-sectional studies published between 2004 and 2010 in the four dermatological journals having the highest 5-year impact factors (≥ 4) were selected. We compared the proportions of STROBE items (STROBE score) adequately reported in each article during three periods, two pre STROBE period (2004-2005 and 2006-2007) and one post STROBE period (2008-2010). Segmented regression analysis of interrupted time series was also performed. RESULTS Of the 456 included articles, 187 (41%) reported cohort studies, 166 (36.4%) cross-sectional studies, and 103 (22.6%) case-control studies. The median STROBE score was 57% (range, 18%-98%). Before-after analysis evidenced significant STROBE score increases between the two pre-STROBE periods and between the earliest pre-STROBE period and the post-STROBE period (median score2004-05 48% versus median score2008-10 58%, p<0.001) but not between the immediate pre-STROBE period and the post-STROBE period (median score2006-07 58% versus median score2008-10 58%, p = 0.42). In the pre STROBE period, the six-monthly mean STROBE score increased significantly, by 1.19% per six-month period (absolute increase 95%CI, 0.26% to 2.11%, p = 0.016). By segmented analysis, no significant changes in STROBE score trends occurred (-0.40%; 95%CI, -2.20 to 1.41; p = 0.64) in the post STROBE statement publication. INTERPRETATION The quality of reports increased over time but was not affected by STROBE. Our findings raise concerns about the relevance of uncontrolled before-after analysis for estimating the impact of guidelines.
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Affiliation(s)
- Sylvie Bastuji-Garin
- Université Paris Est Créteil (UPEC), LIC EA4393 (Laboratoire d'Investigation Clinique), Créteil, France
- AP-HP, Hôpital Henri-Mondor, Department of Clinical Research and Public Health, Créteil, France
- AP-HP, Hôpital Henri-Mondor, Unité de Recherche Clinique (URC), Créteil, France
- * E-mail:
| | - Emilie Sbidian
- Université Paris Est Créteil (UPEC), LIC EA4393 (Laboratoire d'Investigation Clinique), Créteil, France
- AP-HP, Hôpital Henri-Mondor, Department of Dermatology, Créteil, France
| | | | - Emilie Ferrat
- Université Paris Est Créteil (UPEC), LIC EA4393 (Laboratoire d'Investigation Clinique), Créteil, France
- Université Paris Est Créteil (UPEC), Faculté de Medecine, Department of General Practice, Créteil, France
| | | | | | - Florence Canoui-Poitrine
- Université Paris Est Créteil (UPEC), LIC EA4393 (Laboratoire d'Investigation Clinique), Créteil, France
- AP-HP, Hôpital Henri-Mondor, Department of Clinical Research and Public Health, Créteil, France
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Coloma PM, Trifirò G, Patadia V, Sturkenboom M. Postmarketing safety surveillance : where does signal detection using electronic healthcare records fit into the big picture? Drug Saf 2013; 36:183-97. [PMID: 23377696 DOI: 10.1007/s40264-013-0018-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The safety profile of a drug evolves over its lifetime on the market; there are bound to be changes in the circumstances of a drug's clinical use which may give rise to previously unobserved adverse effects, hence necessitating surveillance postmarketing. Postmarketing surveillance has traditionally been carried out by systematic manual review of spontaneous reports of adverse drug reactions. Vast improvements in computing capabilities have provided opportunities to automate signal detection, and several worldwide initiatives are exploring new approaches to facilitate earlier detection, primarily through mining of routinely-collected data from electronic healthcare records (EHR). This paper provides an overview of ongoing initiatives exploring data from EHR for signal detection vis-à-vis established spontaneous reporting systems (SRS). We describe the role SRS has played in regulatory decision making with respect to safety issues, and evaluate the potential added value of EHR-based signal detection systems to the current practice of drug surveillance. Safety signal detection is both an iterative and dynamic process. It is in the best interest of public health to integrate and understand evidence from all possibly relevant information sources on drug safety. Proper evaluation and communication of potential signals identified remains an imperative and should accompany any signal detection activity.
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Affiliation(s)
- Preciosa M Coloma
- Ee-2116, Department of Medical Informatics, Erasmus Medical Centre, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Golder S, Loke YK, Bland M. Comparison of pooled risk estimates for adverse effects from different observational study designs: methodological overview. PLoS One 2013; 8:e71813. [PMID: 23977151 PMCID: PMC3748094 DOI: 10.1371/journal.pone.0071813] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 07/03/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND A diverse range of study designs (e.g. case-control or cohort) are used in the evaluation of adverse effects. We aimed to ascertain whether the risk estimates from meta-analyses of case-control studies differ from that of other study designs. METHODS Searches were carried out in 10 databases in addition to reference checking, contacting experts, and handsearching key journals and conference proceedings. Studies were included where a pooled relative measure of an adverse effect (odds ratio or risk ratio) from case-control studies could be directly compared with the pooled estimate for the same adverse effect arising from other types of observational studies. RESULTS We included 82 meta-analyses. Pooled estimates of harm from the different study designs had 95% confidence intervals that overlapped in 78/82 instances (95%). Of the 23 cases of discrepant findings (significant harm identified in meta-analysis of one type of study design, but not with the other study design), 16 (70%) stemmed from significantly elevated pooled estimates from case-control studies. There was associated evidence of funnel plot asymmetry consistent with higher risk estimates from case-control studies. On average, cohort or cross-sectional studies yielded pooled odds ratios 0.94 (95% CI 0.88-1.00) times lower than that from case-control studies. INTERPRETATION Empirical evidence from this overview indicates that meta-analysis of case-control studies tend to give slightly higher estimates of harm as compared to meta-analyses of other observational studies. However it is impossible to rule out potential confounding from differences in drug dose, duration and populations when comparing between study designs.
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Affiliation(s)
- Su Golder
- Centre for Reviews and Dissemination (CRD), University of York, York, United Kingdom
| | - Yoon K. Loke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Martin Bland
- Department of Health Sciences, University of York, York, United Kingdom
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Abstract
Commonly used statistical measures to quantify the likelihood of an adverse drug event (ADE) from clinical trials include risk ratio; odds ratio; and number needed to harm (NNH), the reciprocal of absolute risk. This critical review focused on NNH, specifically on its limitations in controlled trials with psychotropic medication. Data for this evaluation were obtained primarily from articles in MEDLINE from 1988 to 2012. Limitations of NNH were found to include the following: a) arbitrary binary cutoffs for continuous measures, b) limited use of confidence intervals, c) limited adjustments for potential baseline confounders, d) limited adjustments for differences in dose and treatment duration, e) rare consideration of high attrition rates, f) variable use of the term harm, g) oversimplified single harm comparisons, h) frequent biased design and reporting, i) undue emphasis on less severe ADEs, j) application primarily to short-term clinical trials, and k) little or no generalizability in community practice. In sum, the NNH metric supplies very limited information on the risks of psychotropic medication. Postmarketing surveillance of community treatment populations using case-control methodology provides far more useful data on serious ADEs.
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Boudiba A. Significance of observational data on type 2 diabetes management in North Africa. Diabetes Res Clin Pract 2013; 101 Suppl 1:S1-3. [PMID: 23958567 DOI: 10.1016/s0168-8227(13)00268-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Alves C, Macedo AF, Marques FB. Sources of information used by regulatory agencies on the generation of drug safety alerts. Eur J Clin Pharmacol 2013; 69:2083-94. [PMID: 23893047 DOI: 10.1007/s00228-013-1564-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 07/10/2013] [Indexed: 01/30/2023]
Abstract
PURPOSE The study of the grounds on which data regulatory authorities base their decisions on drug safety evaluations is an important clinical and public health issue. The aim of this study was to review the type and publication status of data sources supporting benefit/risk ratio re-evaluations conducted by the major regulatory authorities on safety issues. METHODS A website search was carried out to identify all safety alerts published by the U.S Food and Drugs Administration, Health Canada, European Medicines Agency and the Australian Therapeutics Goods Administration. Safety alerts were included if the causal relation between a suspected drug exposure and the occurrence of an adverse event was evaluated for the first time between 2010 and 2012. Type of data sources evaluated by these regulatory authorities, publication status of the data sources and status of the drug label section with respect to updating were evaluated. RESULTS A total of 59 safety alerts were included in this study. Of these, 33 (56%) were supported by post-marketing spontaneous reports, 24 (41%) evaluated randomized clinical trials, 16 evaluated cohort studies (27%), 13 were case-control studies (22%) and 11 evaluated case report/case series (17%). Twenty-three safety alerts (39%) were issued based. on unpublished evidence, corresponding mainly to post-marketing spontaneous reports. The "Warnings and precautions section" was the drug label section most frequently updated (n = 40; 68%). CONCLUSION Despite the different lengths of time taken by the different regulatory authorities to come to similar decisions on the same issues-an issue which would seem to deserve further harmonization-post-marketing spontaneous reports have supported most of the benefit/risk ratio re-evaluations, thereby confirming the value of such re-evaluations in detecting unknown adverse events.
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Affiliation(s)
- Carlos Alves
- Centre for Health Technology Assessment and Drug Research (CHAD), Association for Innovation and Biomedical Research on Light and Image (AIBILI), Azinhaga de Santa Comba, Celas, Coimbra, 3000-548, Portugal,
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Deciding what type of evidence and outcomes to include in guidelines: article 5 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Ann Am Thorac Soc 2013; 9:243-50. [PMID: 23256166 DOI: 10.1513/pats.201208-058st] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Professional societies, like many other organizations around the world, have recognized the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the fifth of a series of 14 articles that were prepared by an international panel to advise guideline developers in respiratory and other diseases on approaches for guideline development. This article focuses on what type of evidence and outcomes to include in guidelines. METHODS In this review we addressed the following topics and questions. (1) What methods should be used to select important outcomes? (2) What types of outcomes should be considered? (3) What sources of evidence should be considered? (4) How should the importance of outcomes be ranked? (5) How to deal with surrogate outcomes. (6) What issues related to outcomes should be considered in the evidence review? (7) What quality of evidence should be used? (8) How to interpret the effect on outcomes. (9) How to incorporate outcomes related to harm. We based our responses on a PubMed literature review, prior reviews, relevant methodological research, and workshop discussions. RESULTS AND DISCUSSION Guideline panels should use transparent and systematic methods to select both the evidence and important outcomes, with input from groups that represent a wide range of expertise and constituencies. Outcomes should address both benefits and downsides, with consideration of the definitions, severity, and time course of the outcomes. Guideline panels should use a transparent approach to rank outcome importance recognizing that stakeholder and patient values and preferences may vary. Intermediate and surrogate outcomes are frequently reported, but their correlation with patient important outcomes may be low. A guideline panel should determine a priori the magnitude of effect judged clinically significant, factors that may influence outcome reporting, and whether different ways of measuring the outcomes permit the outcomes to be combined. Comprehensive identification of the evidence includes the use of multiple data sources. While randomized controlled trials (RCTs) provide the highest quality evidence, reviewers of evidence also need to consider nonrandomized studies such as case series, registries, and case-control studies if randomized trials are not available. This is particularly true for harms. The outcomes reported from RCTs may not always directly apply to clinical practice settings (i.e., they may not be generalizable).
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Coloma PM, Avillach P, Salvo F, Schuemie MJ, Ferrajolo C, Pariente A, Fourrier-Réglat A, Molokhia M, Patadia V, van der Lei J, Sturkenboom M, Trifirò G. A reference standard for evaluation of methods for drug safety signal detection using electronic healthcare record databases. Drug Saf 2013; 36:13-23. [PMID: 23315292 DOI: 10.1007/s40264-012-0002-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The growing interest in using electronic healthcare record (EHR) databases for drug safety surveillance has spurred development of new methodologies for signal detection. Although several drugs have been withdrawn postmarketing by regulatory authorities after scientific evaluation of harms and benefits, there is no definitive list of confirmed signals (i.e. list of all known adverse reactions and which drugs can cause them). As there is no true gold standard, prospective evaluation of signal detection methods remains a challenge. OBJECTIVE Within the context of methods development and evaluation in the EU-ADR Project (Exploring and Understanding Adverse Drug Reactions by integrative mining of clinical records and biomedical knowledge), we propose a surrogate reference standard of drug-adverse event associations based on existing scientific literature and expert opinion. METHODS The reference standard was constructed for ten top-ranked events judged as important in pharmacovigilance. A stepwise approach was employed to identify which, among a list of drug-event associations, are well recognized (known positive associations) or highly unlikely ('negative controls') based on MEDLINE-indexed publications, drug product labels, spontaneous reports made to the WHO's pharmacovigilance database, and expert opinion. Only drugs with adequate exposure in the EU-ADR database network (comprising ≈60 million person-years of healthcare data) to allow detection of an association were considered. Manual verification of positive associations and negative controls was independently performed by two experts proficient in clinical medicine, pharmacoepidemiology and pharmacovigilance. A third expert adjudicated equivocal cases and arbitrated any disagreement between evaluators. RESULTS Overall, 94 drug-event associations comprised the reference standard, which included 44 positive associations and 50 negative controls for the ten events of interest: bullous eruptions; acute renal failure; anaphylactic shock; acute myocardial infarction; rhabdomyolysis; aplastic anaemia/pancytopenia; neutropenia/agranulocytosis; cardiac valve fibrosis; acute liver injury; and upper gastrointestinal bleeding. For cardiac valve fibrosis, there was no drug with adequate exposure in the database network that satisfied the criteria for a positive association. CONCLUSION A strategy for the construction of a reference standard to evaluate signal detection methods that use EHR has been proposed. The resulting reference standard is by no means definitive, however, and should be seen as dynamic. As knowledge on drug safety evolves over time and new issues in drug safety arise, this reference standard can be re-evaluated.
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Affiliation(s)
- Preciosa M Coloma
- Department of Medical Informatics, Erasmus Medical Center, Postbus 2040, 3000, CA, Rotterdam, The Netherlands.
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Osimani B. Until RCT proven? On the asymmetry of evidence requirements for risk assessment. J Eval Clin Pract 2013; 19:454-62. [PMID: 23692227 DOI: 10.1111/jep.12039] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2013] [Indexed: 02/03/2023]
Abstract
The problem of collecting, analysing and evaluating evidence on adverse drug reactions is an example of the more general class of epistemological problems related to scientific inference and prediction, as well as a central problem of health care practice. Philosophical discussions have analysed critically the methodological pitfalls and epistemological implications of evidence assessment in medicine; however, they have focused predominantly on evidence of treatment efficacy. Most of this work is devoted to statistical methods of causal inference with a special focus on the privileged role assigned to randomized controlled trials (RCTs) in evidence-based medicine. Regardless of whether the RCT's privilege holds for efficacy assessment, it is nevertheless important to make a distinction between causal inference in relation to intended and unintended effects, in that the unknowns at stake are heterogeneous in the two contexts. This point has been emphasized by epidemiologists in the last decade. Their primary focus is methodological and regards the fact that bias and confounding factors do not affect studies on intended and unintended effects in the same way. However, deeper concerns ground the intuition for such a distinction; these are related to the constraints we impose on evidence and their epistemological justification. My thesis is that such constraints ought to be understood as being different in evidence for risk versus for efficacy. I present the recent debate on the causal association between acetaminophen and asthma in order to illustrate the point at issue. The upshot of my analysis is that different epistemologies confer different methodological choices, which in turn bring about relevant practical implications such as the decision to restrict or suspend drug use rather than leaving it on the market. Thus, it is worth considering the criteria underlying our evidence constraints because they may be ill suited to the purpose for which they are used.
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Seegers V, Trinquart L, Boutron I, Ravaud P. Comparison of treatment effect estimates for pharmacological randomized controlled trials enrolling older adults only and those including adults: a meta-epidemiological study. PLoS One 2013; 8:e63677. [PMID: 23723992 PMCID: PMC3665786 DOI: 10.1371/journal.pone.0063677] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 04/05/2013] [Indexed: 11/29/2022] Open
Abstract
CONTEXT Older adults are underrepresented in clinical research. To assess therapeutic efficacy in older patients, some randomized controlled trials (RCTs) include older adults only. OBJECTIVE To compare treatment effects between RCTs including older adults only (elderly RCTs) and RCTs including all adults (adult RCTs) by a meta-epidemiological approach. METHODS All systematic reviews published in the Cochrane Library (Issue 4, 2011) were screened. Eligible studies were meta-analyses of binary outcomes of pharmacologic treatment including at least one elderly RCT and at least one adult RCT. For each meta-analysis, we compared summary odds ratios for elderly RCTs and adult RCTs by calculating a ratio of odds ratios (ROR). A summary ROR was estimated across all meta-analyses. RESULTS We selected 55 meta-analyses including 524 RCTs (17% elderly RCTs). The treatment effects differed beyond that expected by chance for 7 (13%) meta-analyses, showing more favourable treatment effects in elderly RCTs in 5 cases and in adult RCTs in 2 cases. The summary ROR was 0.91 (95% CI, 0.77-1.08, p = 0.28), with substantial heterogeneity (I(2) = 51% and τ(2) = 0.14). Sensitivity and subgroup analyses by type-of-age RCT (elderly RCTs vs RCTs excluding older adults and vs RCTs of mixed-age adults), type of outcome (mortality or other) and type of comparator (placebo or active drug) yielded similar results. CONCLUSIONS The efficacy of pharmacologic treatments did not significantly differ, on average, between RCTs including older adults only and RCTs of all adults. However, clinically important discrepancies may occur and should be considered when generalizing evidence from all adults to older adults.
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Affiliation(s)
- Valérie Seegers
- Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Paris, France
- INSERM U738, Paris, France
| | - Ludovic Trinquart
- Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Paris, France
- INSERM U738, Paris, France
- Université Paris Descartes – Sorbonne Paris Cité, Paris, France
- French Cochrane Centre, Paris, France
| | - Isabelle Boutron
- Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Paris, France
- INSERM U738, Paris, France
- Université Paris Descartes – Sorbonne Paris Cité, Paris, France
- French Cochrane Centre, Paris, France
| | - Philippe Ravaud
- Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Paris, France
- INSERM U738, Paris, France
- Université Paris Descartes – Sorbonne Paris Cité, Paris, France
- French Cochrane Centre, Paris, France
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, United States of America
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Abstract
Some risk exposures, including many medical and surgical procedures, typically carry hazards of death that are difficult to convey and appreciate in absolute terms. I propose presenting the death risk as a condensed life experience (i.e., the equivalent amount of life T that would carry the same cumulative mortality hazard for a person of the same age and sex based on life tables). For example, if the risk of death during an elective 1-hour procedure is 0.01%, and same-age and same-sex people have a 0.01% death risk over 1 month, one can inform the patient that "this procedure carries the same death risk as living 1 month of normal life." Comparative standards from other risky activities or from a person with the same disease at the same stage and same predictive profile could also be used. A complementary metric that may be useful to consider is the death intensity. The death intensity λ is the hazard function that shows the fold-risk estimate of dying compared with the reference person. The death intensity can vary substantially for different phases of the event, operation, or procedure (e.g., intraoperative, early postoperative, late postoperative), and this variability may also be useful to convey. T will vary depending on the time window for which it is computed. I present examples for calculating T and λ using literature data on accidents, ascent to Mount Everest, and medical and surgical procedures.
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Affiliation(s)
- John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Osimani B. The precautionary principle in the pharmaceutical domain: a philosophical enquiry into probabilistic reasoning and risk aversion. HEALTH RISK & SOCIETY 2013. [DOI: 10.1080/13698575.2013.771736] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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The quality of reporting in clinical research: the CONSORT and STROBE initiatives. Aging Clin Exp Res 2013; 25:9-15. [PMID: 23740628 DOI: 10.1007/s40520-013-0007-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 08/09/2012] [Indexed: 10/27/2022]
Abstract
Inaccurate reporting of data hampers the generalizability and the correct interpretation of results of scientific medical papers. The Consolidated Standards of Reporting Trials (CONSORT) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiatives, both included in the Enhancing the Quality and Transparency of Health Research (EQUATOR) international network, have elaborated appropriate guidelines in order to improve the transparence, clearness and completeness of scientific literature. The CONSORT statement consists of a 25 items checklist and a flow-chart diagram which provide guidance to Authors on how to report randomized clinical trials. The STROBE is a checklist of 22 items which should be addressed when observational studies (case-control, cohort and cross-sectional) are made up. Many editorial committees and prestigious international journals have now embraced these guidelines to improve the quality and methodology of their scientific reports.
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Cornelius VR, Sauzet O, Williams JE, Ayis S, Farquhar-Smith P, Ross JR, Branford RA, Peacock JL. Adverse event reporting in randomised controlled trials of neuropathic pain: Considerations for future practice. Pain 2013; 154:213-220. [DOI: 10.1016/j.pain.2012.08.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 08/08/2012] [Accepted: 08/24/2012] [Indexed: 10/27/2022]
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Powers WJ, Clarke WR, Adams HP, Derdeyn CP, Grubb RL. Commentary: Extracranial-intracranial bypass for stroke in 2012: response to the critique of the carotid occlusion surgery study "It was déjà vu all over again". Neurosurgery 2013; 71:E772-6. [PMID: 22899445 DOI: 10.1227/neu.0b013e318268c7d3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Wolbers JG, Dallenga AHG, Mendez Romero A, van Linge A. What intervention is best practice for vestibular schwannomas? A systematic review of controlled studies. BMJ Open 2013; 3:bmjopen-2012-001345. [PMID: 23435793 PMCID: PMC3586173 DOI: 10.1136/bmjopen-2012-001345] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Largely, watchful waiting is the initial policy for patients with small-sized or medium-sized vestibular schwannoma, because of slow growth and relatively minor complaints, that do not improve by an intervention. If intervention (microsurgery, radiosurgery or fractionated radiotherapy) becomes necessary, the choice of intervention appears to be driven by the patient's or clinician's preference rather than by evidence based. This study addresses the existing evidence based on controlled studies of these interventions. DESIGN A systematic Boolean search was performed focused on controlled intervention studies. The quality of the retrieved studies was assessed based on the Sign-50 criteria on cohort studies. DATA SOURCES Pubmed/Medline, Embase, Cochrane Central Register of Controlled Trials and reference lists. STUDY SELECTION Six eligibility criteria included a controlled intervention study on a newly diagnosed solitary, vestibular schwannoma reporting on clinical outcomes. Two prospective and four retrospective observational, controlled studies published before November 2011 were selected. DATA ANALYSIS Two reviewers independently assessed the methodological quality of the studies and extracted the outcome data using predefined formats. RESULTS Neither randomised studies, nor controlled studies on fractionated radiotherapy were retrieved. Six studies compared radiosurgery and microsurgery in a controlled way. All but one were confined to solitary tumours less than 30 mm in diameter and had no earlier interventions. Four studies qualified for trustworthy conclusions. Among all four, radiosurgery showed the best outcomes: there were no direct mortality, no surgical or anaesthesiological complications, but better facial nerve outcome, better preservation of useful hearing and better quality of life. CONCLUSIONS The available evidence indicates radiosurgery to be the best practice for solitary vestibular schwannomas up to 30 mm in cisternal diameter.
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Affiliation(s)
- John G Wolbers
- Department of Neurosurgery, Erasmus University Medical Centre,Rotterdam, The Netherlands
| | - Alof HG Dallenga
- Department of Neurosurgery, Erasmus University Medical Centre,Rotterdam, The Netherlands
| | - Alejandra Mendez Romero
- Department of Radiation Oncology, Erasmus University Medical Centre, Rotterdam,The Netherlands
| | - Anne van Linge
- Department of Otorhinolaryngology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Kiri VA. A pathway to improved prospective observational post-authorization safety studies. Drug Saf 2012; 35:711-24. [PMID: 22861669 DOI: 10.1007/bf03261968] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Randomized controlled trials (RCTs) are the gold standard for assessing the efficacy of drugs but not necessarily so for drug safety where inadequate power to detect either multiple or rare adverse events is a major handicap. Furthermore, the conditions under which drugs are approved for market use are often different from the settings in actual use. Indeed, with their control mechanisms, trials are by design largely inadequate for the identification of potential safety signals, especially of the rare type, hence the value of postmarketing surveillance and risk management plan-based activities. Today, clinical trials constitute only a part of the research that goes into assessing the safety of drugs. Observational studies, where the investigators merely collect data on treatments received by patients and their health status in routine clinical practice are increasing in uptake because they reflect the real-life utility of drugs, despite the absence of random treatment assignment. Although such studies generally provide less compelling evidence than RCTs, they can be far more useful to drug safety assessment activities than generally acknowledged. An increasing number of post-authorization safety studies (PASS) within the European Medicines Agency's jurisdiction are of the observational type - considered perhaps as more appropriate vehicles for exploring and documenting how products perform in the real world. A similar trend is emerging in the US following the FDA Amendments Act of 2007; since early 2010, an increasing number of post-approval commitments mandated by the FDA include observational studies. However, despite this pattern, not much is known about ongoing efforts to address many of the recognized inadequacies associated with existing methodologies and practices currently adopted in observational PASS. This current opinion presents an overview of some of the main challenges we face in prospective observational PASS, mainly from practical experience, and proposes certain steps for improvement.
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Affiliation(s)
- Victor A Kiri
- Centre of Biostatistics, University of Limerick, Limerick, Ireland.
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Colmers IN, Bowker SL, Tjosvold LA, Johnson JA. Insulin use and cancer risk in patients with type 2 diabetes: a systematic review and meta-analysis of observational studies. DIABETES & METABOLISM 2012; 38:485-506. [PMID: 23159131 DOI: 10.1016/j.diabet.2012.08.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 07/30/2012] [Accepted: 08/01/2012] [Indexed: 12/21/2022]
Abstract
AIMS To determine whether data from observational studies supports the hypothesis of an increased risk of overall and site-specific cancer among individuals with diabetes using exogenous insulin therapies. METHODS We conducted a comprehensive search of nine key biomedical databases for all years up to December 2011, restricted to the English language. Data from cohort and nested case-control studies were included in random effects meta-analyses of site-specific and overall cancer incidence comparing ever use and new use of: (1) insulin to no insulin and; (2) insulin glargine to other insulins. RESULTS The search yielded 3052 unique citations, of which 19 were selected for inclusion, representing data for 1,332,120 people and 41,947 cancers. Pancreatic cancer risk was increased among new users of insulin (RR: 3.18, 95%CI: 3.27-3.71, I(2)=32%). New use of insulin glargine was associated with an increased risk of pancreatic cancer (RR: 1.63, 95%CI: 1.05-2.51, I(2)=0%) and prostate cancers (RR: 2.68, 95%CI: 1.50-4.79, I(2)=0%) but a decreased risk of colorectal cancer (RR: 0.78, 95%CI: 0.64-0.94, I(2)=15%). CONCLUSION New use of insulin or insulin glargine was associated with an increased risk of pancreatic cancer, possibly due to reverse causality. New use of insulin glargine was associated with a decreased risk of colorectal cancer but an increased risk of prostate cancer. Our results should be interpreted with caution due to limitations of included studies.
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Affiliation(s)
- I N Colmers
- Department of Public Health Sciences, University of Alberta, 2-040 Li Ka Shing Center Edmonton, Alberta, T6G 2E1 Canada
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A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction. Surg Endosc 2012; 27:832-42. [PMID: 23052501 DOI: 10.1007/s00464-012-2520-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 07/31/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies. METHODS Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon. RESULTS Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %. CONCLUSIONS In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.
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Colmers IN, Bowker SL, Johnson JA. Thiazolidinedione use and cancer incidence in type 2 diabetes: a systematic review and meta-analysis. DIABETES & METABOLISM 2012; 38:475-84. [PMID: 23041441 DOI: 10.1016/j.diabet.2012.06.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 06/18/2012] [Accepted: 06/20/2012] [Indexed: 12/17/2022]
Abstract
AIMS Evidence suggests thiazolidinediones (TZDs) may modify the relationship between type 2 diabetes and cancer incidence. We aimed to summarize data from randomized controlled trials (RCTs) and observational studies to examine risk of overall and site-specific cancers with TZD use in individuals with type 2 diabetes. METHODS We searched 12 key biomedical databases and seven grey literature sources up to June 2011, without language restrictions. We performed separate meta-analyses according to cancer site and study design, comparing ever-use to never-use of TZDs, and pioglitazone alone. RESULTS The search yielded 1338 unique citations; we included four RCT, seven cohort and nine nested case-control studies, contributing data from 2.5 million people. Estimates from observational studies suggested any TZD use was associated with a decreased risk of colorectal (pooled RR: 0.93, 95%CI 0.87-1.00, P=0.04, I(2)=30%), lung (pooled RR: 0.91, 95%CI 0.84-0.98, P=0.02, heterogeneity (I(2))=35%) and breast (pooled RR: 0.89, 95%CI 0.81-0.98, P=0.02, I(2)=44%) cancer. Risk of overall cancer with TZD use was not significantly modified in RCTs (pooled RR: 0.92, 95%CI 0.79-1.07, P=0.26, I(2)=0%) or observational studies (pooled OR: 0.95, 95%CI 0.78-1.16, P=0.63, I(2)=70%). Pioglitazone use was, however, associated with a decreased risk of overall cancer (colorectal, lung, breast, prostate and renal sub-sites combined) in observational studies (pooled RR: 0.95, 95%CI 0.91-0.99, P=0.009, I(2)=0%). CONCLUSIONS Our findings suggest that use of TZDs is associated with a modest but significantly decreased risk of lung, colorectal and breast cancers. Results were limited by the paucity of studies designed to answer our research question. Further evaluation of TZD use, cancer risk factors and potential confounders is required.
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Affiliation(s)
- I N Colmers
- Department of Public Health Sciences, University of Alberta, 2-040 Li Ka Shing Center, Edmonton, AB, T6G 2E1 Canada
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Kirpalani H, Zupancic JAF. Do transfusions cause necrotizing enterocolitis? The complementary role of randomized trials and observational studies. Semin Perinatol 2012; 36:269-76. [PMID: 22818547 DOI: 10.1053/j.semperi.2012.04.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A systematic review and a meta-analysis of the published literature on the association between transfusions in newborns and the occurrence of transfusion-associated necrotizing enterocolitis were performed. We discuss the differences between findings in randomized trials, and the results of observational studies that first explored this putative link. We suggest the following framework: where observational studies play a hypothesis generating- role for therapies and harm, and randomized studies allow an acid test of that hypothesis. It is acknowledged that not all questions can be subject to a randomized evaluation, but argued that this particular association is amenable to such a test.
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Affiliation(s)
- Haresh Kirpalani
- Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104-4399, USA.
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Wagner AD, Thomssen C, Haerting J, Unverzagt S. Vascular-endothelial-growth-factor (VEGF) targeting therapies for endocrine refractory or resistant metastatic breast cancer. Cochrane Database Syst Rev 2012:CD008941. [PMID: 22786517 DOI: 10.1002/14651858.cd008941.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Vascular-endothelial-growth-factor (VEGF) is a key mediator of angiogenesis. VEGF-targeting therapies have shown significant benefits and been successfully integrated in routine clinical practice for other types of cancer, such as metastatic colorectal cancer. By contrast, individual trial results in metastatic breast cancer (MBC) are highly variable and their value is controversial. OBJECTIVES To evaluate the benefits (in progression-free survival (PFS) and overall survival (OS)) and harms (toxicity) of VEGF-targeting therapies in patients with hormone-refractory or hormone-receptor negative metastatic breast cancer. SEARCH METHODS Searches of CENTRAL, MEDLINE, EMBASE, the Cochrane Breast Cancer Group's Specialised Register, registers of ongoing trials and proceedings of conferences were conducted in January and September 2011, starting in 2000. Reference lists were scanned and members of the Cochrane Breast Cancer Group, experts and manufacturers of relevant drug were contacted to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials (RCTs) to evaluate treatment benefit and non-randomised studies in the routine oncology practice setting to evaluate treatment harms. DATA COLLECTION AND ANALYSIS We performed data collection and analysis according to the published protocol. Individual patient data was sought but not provided. Therefore, the meta-analysis had to be based on published data. Summary statistics for the primary endpoint (PFS) were hazard ratios (HRs). MAIN RESULTS We identified seven RCTs, one register, and five ongoing trials from a total of 347 references. The published trials for VEGF-targeting drugs in MBC were limited to bevacizumab. Four trials, including a total of 2886 patients, were available for the comparison of first-line chemotherapy, with versus without bevacizumab. PFS (HR 0.67; 95% confidence interval (CI) 0.61 to 0.73) and response rate were significantly better for patients treated with bevacizumab, with moderate heterogeneity regarding the magnitude of the effect on PFS. For second-line chemotherapy, a smaller, but still significant benefit in terms of PFS could be demonstrated for patients treated with bevacizumab (HR 0.85; 95% CI 0.73 to 0.98), as well as a benefit in tumour response. However, OS did not differ significantly, neither in first- (HR 0.93; 95% CI 0.84 to 1.04), nor second-line therapy (HR 0.98; 95% CI 0.83 to 1.16). Quality of life (QoL) was evaluated in four trials but results were published for only two of these with no relevant impact. Subgroup analysis stated a significant greater benefit for patients with previous (taxane) chemotherapy and patients with hormone-receptor negative status. Regarding toxicity, data from RCTs and registry data were consistent and in line with the known toxicity profile of bevacizumab. While significantly higher rates of adverse events (AEs) grade III/IV (odds ratio (OR) 1.77; 95% CI 1.44 to 2.18) and serious adverse events (SAEs) (OR 1.41; 95% CI 1.13 to 1.75) were observed in patients treated with bevacizumab, rates of treatment-related deaths were lower in patients treated with bevacizumab (OR 0.60; 95% CI 0.36 to 0.99). AUTHORS' CONCLUSIONS The overall patient benefit from adding bevacizumab to first- and second-line chemotherapy in metastatic breast cancer can at best be considered as modest. It is dependent on the type of chemotherapy used and limited to a prolongation of PFS and response rates in both first- and second-line therapy, both surrogate parameters. In contrast, bevacizumab has no significant impact on the patient-related secondary outcomes of OS or QoL, which indicate a direct patient benefit. For this reason, the clinical value of bevacizumab for metastatic breast cancer remains controversial.
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Affiliation(s)
- Anna Dorothea Wagner
- 1Fondation du Centre Pluridisciplinaire d’Oncologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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Baird-Heinz HE, Van Schoick AL, Pelsor FR, Ranivand L, Hungerford LL. A systematic review of the safety of potassium bromide in dogs. J Am Vet Med Assoc 2012; 240:705-15. [PMID: 22380809 DOI: 10.2460/javma.240.6.705] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To critically evaluate and summarize available information on the safety of potassium bromide in dogs. DESIGN Systematic review. SAMPLE 111 references reporting safety information relevant to potassium bromide published between 1938 and 2011. PROCEDURES PubMed searches without date limitations were conducted with the terms "potassium bromide" and "sodium bromide" in December 2009 and October 2011. Additional articles were identified through examination of article reference lists and book chapters on seizures in dogs and pharmacology. RESULTS Reversible neurologic signs were the most consistently reported toxicoses and were generally associated with adjunctive potassium bromide treatment or high serum bromide concentrations. Dermatologic and respiratory abnormalities were rare in dogs. Insufficient information was available to assess the effects of potassium bromide on behavior or to determine the incidence of vomiting, weight gain, polyphagia, pancreatitis, polyuria, polydipsia, or reproductive abnormalities associated with potassium bromide administration. Evidence suggested that administration of potassium bromide with food may alleviate gastrointestinal irritation and that monitoring for polyphagia, thyroid hormone abnormalities, and high serum bromide concentrations may be beneficial. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that potassium bromide is not an appropriate choice for treatment of every dog with seizures and that practitioners should tailor therapeutic regimens and clinical monitoring to each dog. Abrupt dietary changes or fluid therapy may compromise seizure control or increase the likelihood of adverse events. Availability of an appropriately labeled, approved potassium bromide product could provide better assurance for veterinarians and their clients of the quality, safety, and effectiveness of the product for veterinary use.
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Affiliation(s)
- Hope E Baird-Heinz
- Center for Veterinary Medicine, US FDA, 7519 Standish Pl, Rockville, MD 20855, USA
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98
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Johnson JA, Carstensen B, Witte D, Bowker SL, Lipscombe L, Renehan AG. Diabetes and cancer (1): evaluating the temporal relationship between type 2 diabetes and cancer incidence. Diabetologia 2012; 55:1607-18. [PMID: 22476947 DOI: 10.1007/s00125-012-2525-1] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 02/06/2012] [Indexed: 12/12/2022]
Abstract
Substantial evidence suggests that people with type 2 diabetes have an increased risk of developing several types of cancers. These associations may be due to a number of direct and indirect mechanisms. Observational studies of these associations, including the potential role for glucose-lowering therapy, are being increasingly reported, but face a number of methodological challenges. This paper is the first of two review papers addressing methodological aspects underpinning the interpretations of links between diabetes and cancer, and suggests potential approaches to study designs to be considered in observational studies. This paper reviews factors related to cancer incidence in the diabetic population; the second paper relates to studies of cancer mortality.
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Affiliation(s)
- J A Johnson
- School of Public Health, University of Alberta, 2040 Li Ka Shing Center, Edmonton, AB, Canada T6G 2E1.
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Palkowitsch P, Lengsfeld P, Stauch K, Heinsohn C, Kwon ST, Zhang SX, Liang CH. Safety and diagnostic image quality of iopromide: results of a large non-interventional observational study of European and Asian patients (IMAGE). Acta Radiol 2012; 53:179-86. [PMID: 22184683 DOI: 10.1258/ar.2011.110359] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Iodine-based contrast agents such as iopromide play a central role in improving the diagnostic quality of imaging modalities using ionizing radiation. PURPOSE To investigate the safety and diagnostic image quality of iopromide in the routine clinical setting. MATERIAL AND METHODS This was an international, multicenter, prospective, single-arm, non-interventional study (NIS). The study was performed in out- and inpatients in 738 study centers in 21 countries in Europe and Asia. Iopromide was administered in a routine manner, in compliance with the local package insert. The use of premedication was at the discretion of the attending physician. Case report forms for 44,835 patients were analyzed (57.4% men). The median age of the patients was 55 years. RESULTS For the vast majority of patients (94.8%), the contrast quality was rated as 'good' (55.8%) or 'excellent' (39.0%). For 1265 (2.8%) patients, there were reports of adverse drug reactions (ADRs) excluding tolerance indicators (TIs) (i.e. injection site warmth, feeling hot, or injection site pain of mild intensity). At least one ADR including TIs was reported in 2415 (5.4%) patients. There were 11 (0.02%) patients with serious ADRs, and no drug-related deaths. Events of injection site warmth and/or feeling hot were reported by 3.5%, nausea and/or vomiting by 0.96%, and urticaria, erythema, and/or rash by 0.54% of patients. Patients at risk for an acute idiosyncratic reaction (i.e. patients with a history of bronchial asthma, allergies, and/or contrast media reaction) had a higher incidence of ADRs compared with the overall study population. At-risk patients who did not receive premedication reported distinctly more ADRs compared with those who received premedication (12.0% versus 5.9%). CONCLUSION Iopromide was shown to be a well-tolerated contrast agent whose usage resulted in high image quality. No unknown ADRs were observed. Premedication with antiallergy drugs should be considered in at-risk patients.
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Affiliation(s)
- Petra Palkowitsch
- Global Medical Affairs Diagnostic Imaging, Bayer HealthCare, Berlin, Germany
| | - Philipp Lengsfeld
- Global Medical Affairs Diagnostic Imaging, Bayer HealthCare, Berlin, Germany
| | - Kathrin Stauch
- Global Non-interventional Studies, Bayer HealthCare, Berlin, Germany
| | | | - Soon Tae Kwon
- Department of Radiology, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Shui-xing Zhang
- Department of Radiology, Guangdong General Hospital/Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chang-hong Liang
- Department of Radiology, Guangdong General Hospital/Guangdong Academy of Medical Sciences, Guangzhou, China
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Benefit–Risk Analysis of Glatiramer Acetate for Relapsing-Remitting and Clinically Isolated Syndrome Multiple Sclerosis. Clin Ther 2012; 34:159-176.e5. [DOI: 10.1016/j.clinthera.2011.12.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 11/22/2011] [Accepted: 12/12/2011] [Indexed: 11/17/2022]
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