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Xiang Y, Feng Y, Qiu J, Zhang R, So HC. Association of COVID-19 vaccination with risks of hospitalization due to cardiovascular and other diseases: A study using data from the UK Biobank. Int J Infect Dis 2024; 145:107080. [PMID: 38701913 DOI: 10.1016/j.ijid.2024.107080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/08/2024] [Accepted: 04/29/2024] [Indexed: 05/05/2024] Open
Abstract
OBJECTIVES To explore whether COVID-19 vaccination protects against hospital admission by preventing infections and severe disease. METHODS We leveraged the UK Biobank and studied associations of COVID-19 vaccination (BioNTech-BNT162b2 or Oxford-AstraZeneca-ChAdOx1) with hospitalizations from cardiovascular and other selected diseases (N = 393,544; median follow-up = 54 days among vaccinated individuals). Multivariable Cox, Poisson regression, propensity score matching, and inverse probability treatment weighting analyses were performed. We also performed adjustment using prescription-time distribution matching, and prior event rate ratio. RESULTS We observed that COVID-19 vaccination (at least one dose), compared with no vaccination, was associated with reduced short-term risks of hospitalizations from stroke (hazard ratio [HR] = 0.178, 95% confidence interval [CI]: 0.127-0.250, P = 1.50e-23), venous thromboembolism (HR = 0.426, CI: 0.270-0.673, P = 2.51e-4), dementia (HR = 0.114, CI: 0.060-0.216; P = 2.24e-11), non-COVID-19 pneumonia (HR = 0.108, CI: 0.080-0.145; P = 2.20e-49), coronary artery disease (HR = 0.563, CI: 0.416-0.762; P = 2.05e-4), chronic obstructive pulmonary disease (HR = 0.212, CI: 0.126-0.357; P = 4.92e-9), type 2 diabetes (HR = 0.216, CI: 0.096-0.486, P = 2.12e-4), heart failure (HR = 0.174, CI: 0.118-0.256, P = 1.34e-18), and renal failure (HR = 0.415, CI: 0.255-0.677, P = 4.19e-4), based on standard Cox regression models. Among the previously mentioned results, reduced hospitalizations for stroke, heart failure, non-COVID-19 pneumonia, and dementia were consistently observed across regression, propensity score matching/inverse probability treatment weighting, prescription-time distribution matching, and prior event rate ratio. The results for two-dose vaccination were similar. CONCLUSIONS Taken together, this study provides further support to the safety and benefits of COVID-19 vaccination, and such benefits may extend beyond reduction of infection risk or severity per se. However, causal relationship cannot be concluded and further studies are required.
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Affiliation(s)
- Yong Xiang
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yaning Feng
- School of Medical Technology and Information Engineering, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jinghong Qiu
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ruoyu Zhang
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hon-Cheong So
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong; KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research of Common Diseases, Kunming Institute of Zoology and The Chinese University of Hong Kong, Hong Kong, China; CUHK Shenzhen Research Institute, Shenzhen, China; Department of Psychiatry, The Chinese University of Hong Kong, Shatin, Hong Kong; Margaret K.L. Cheung Research Centre for Management of Parkinsonism, The Chinese University of Hong Kong, Shatin, Hong Kong; Brain and Mind Institute, The Chinese University of Hong Kong, Shatin, Hong Kong; Hong Kong Branch of the Chinese Academy of Sciences Center for Excellence in Animal Evolution and Genetics, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Dickson EA, Blackburn L, Duffy M, Naumann DN, Brooks A. Engagement with a youth violence intervention programme is associated with lower re-attendance after violent injury: A UK major trauma network observational study. PLoS One 2023; 18:e0292836. [PMID: 37851622 PMCID: PMC10584091 DOI: 10.1371/journal.pone.0292836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 09/29/2023] [Indexed: 10/20/2023] Open
Abstract
The hospital based Redthread Youth Violence Intervention Programme (YVIP) utilises experienced youth workers to support 11-24 year olds following an episode of violent injury, assault or exploitation who present to the Emergency Department (ED) at the East Midlands Major Trauma Centre (MTC), Nottingham, UK. The YVIP aims to promote personal change with the aim of reducing the incidence of further similar events. We conducted a retrospective, observational, cohort study to examine the association between engagement with the YVIP and re-attendance rates to the ED following a referral to Redthread. We also examined factors associated with engagement with the full YVIP. We found that 573 eligible individuals were referred to the YVIP over two years. Assault with body parts 34.9% (n = 200) or a bladed object 29.8% (n = 171) were the commonest reason for referral. A prior event rate ratio (PERR) analysis was used to compare rates of attendance between those who did and did not engage with the full YVIP. Engagement was associated with a reduction in re-attendances of 51% compared to those who did not engage (PERR 0.49 [95% 0.28-0.64]). A previous attendance to the ED by an individual positively predicted engagement. (OR 2.82 [95% CI 1.07-7.42], P = 0.035). A weekend attendance (OR 0.26 [0.15-0.44], P<0.001) and a phone call approach (OR 0.25 [0.14-0.47], P = 0.001), rather than a face-to-face approach by a Redthread worker, negatively impacted engagement. In conclusion, assaults with or without a weapon contributed to a significant proportion of attendances among this age group. The Redthread YVIP was associated with reduced rates of re-attendance to the East Midlands MTC among young persons who engaged with the full programme.
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Affiliation(s)
- Edward A. Dickson
- East Midlands Major Trauma Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, United Kingdom
| | - Lauren Blackburn
- East Midlands Major Trauma Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, United Kingdom
| | - Miriam Duffy
- East Midlands Major Trauma Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, United Kingdom
| | - David N. Naumann
- East Midlands Major Trauma Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, United Kingdom
- Academic Department of Military, Surgery and Trauma, Royal Centre for Defence Medicine, University Hospitals Birmingham NHS, Foundation Trust, Birmingham, United Kingdom
| | - Adam Brooks
- East Midlands Major Trauma Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, United Kingdom
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Jambon-Barbara C, Bernardeau C, Bezin J, Roustit M, Blaise S, Cracowski JL, Khouri C. Use of Bisphosphonates and the Risk of Skin Ulcer: A National Cohort Study Using Data from the French Health Care Claims Database. Drug Saf 2023; 46:905-916. [PMID: 37531074 DOI: 10.1007/s40264-023-01336-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Previous pre-clinical and pharmacovigilance disproportionality analyses highlighted a safety signal of cutaneous ulcer with bisphosphonate use. Therefore, our objective is to evaluate this risk and assess whether unmeasured confounding factors could explain this association. METHODS This study is a population-based cohort study from a representative sample (1/97th) of the French health insurance claims database: Echantillon Généraliste des Bénéficiaires (EGB) from 2006 to 2019. To limit the impact of our study design and methodological choices on any association between skin ulceration and exposure to bisphosphonates, we used several methods: a Cox proportional hazards analysis and a prior event rate ratio (PERR) analysis, using two propensity matched control groups, and either the first episode of incident ulceration or multiple event-time outcomes. RESULTS There were 7402 individuals newly exposed to bisphosphonates matched to 29,605 unexposed individuals on propensity score. The primary outcome was skin ulcer occurrence assessed by at least 2 deliveries of wound dressing during the period of one month. Among 6911 individuals newly exposed to bisphosphonates and 28,072 unexposed individuals with no previous skin ulcer, the Cox regression yielded a hazard ratio (HR) of 1.40 (95% CI 1.26-1.56) for newly exposed individuals. Among 7402 exposed and 29,605 unexposed individuals, the PERR analysis found a non-significant HR of 1.03 (95% CI 0.87-1.24). Results were similar on the different sensitivity analyses. CONCLUSION No association between bisphosphonate and skin ulcers was found in the French population. The association observed in previous pharmacovigilance studies and in the Cox regression analysis is likely due to unmeasured confounding factors.
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Affiliation(s)
- Clément Jambon-Barbara
- Pharmacovigilance Department, Grenoble Alpes University Hospital, 38043, Grenoble, France
| | - Claire Bernardeau
- Pharmacovigilance Department, Grenoble Alpes University Hospital, 38043, Grenoble, France
| | - Julien Bezin
- University Bordeaux, INSERM, BPH, Team AHeaD, U1219, 33000, Bordeaux, France
- Clinical Pharmacology Unit, CHU de Bordeaux, 33000, Bordeaux, France
| | - Matthieu Roustit
- University Grenoble Alpes, Inserm U1300, HP2, 38000, Grenoble, France
- University Grenoble Alpes, Inserm CIC1406, Grenoble Alpes University Hospital, 38000, Grenoble, France
| | - Sophie Blaise
- University Grenoble Alpes, Inserm U1300, HP2, 38000, Grenoble, France
- Department of Vascular Medicine, Grenoble Alpes University Hospital, University Grenoble Alpes, 38000, Grenoble, France
| | - Jean-Luc Cracowski
- Pharmacovigilance Department, Grenoble Alpes University Hospital, 38043, Grenoble, France
- University Grenoble Alpes, Inserm U1300, HP2, 38000, Grenoble, France
| | - Charles Khouri
- Pharmacovigilance Department, Grenoble Alpes University Hospital, 38043, Grenoble, France.
- University Grenoble Alpes, Inserm U1300, HP2, 38000, Grenoble, France.
- University Grenoble Alpes, Inserm CIC1406, Grenoble Alpes University Hospital, 38000, Grenoble, France.
- Centre Regional de Pharmacovigilance, CHU Grenoble Alpes, CS 10217, 38043, Grenoble Cedex 9, France.
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Berg SK, Wallach-Kildemoes H, Rasmussen LR, Nygaard U, Birk NM, Bundgaard H, Ersbøll AK, Thygesen LC, Nielsen SD, Christensen AV. Symptom-Specific Hospital Contacts in 12-18-Year-Olds Vaccinated against COVID-19: A Danish Register-Based Cohort Study. Vaccines (Basel) 2023; 11:1049. [PMID: 37376438 DOI: 10.3390/vaccines11061049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
In this register-based real-life cohort study, changes in symptom-specific hospital contacts among 12-18-year-olds following two doses of the BNT162b2 COVID-19 vaccine compared to unvaccinated peers were investigated. Using national register data, vaccinated and unvaccinated adolescents were sex and age-matched each week during the inclusion period from May to September 2021. Symptom-specific hospital contacts covering ICD-10 R diagnoses were assessed before first the vaccine dose and after the second vaccine dose. Taking previous rates of symptom-specific hospital contacts into account, differences between vaccinated and unvaccinated adolescents were found. For some hospital contacts, higher rates were seen among the vaccinated, and for others, higher rates were seen among the unvaccinated. Unspecific cognition symptoms may be important to monitor in vaccinated girls, and likewise for throat and chest pain in vaccinated boys within the first months post-vaccination. In perspective, symptom-specific hospital contacts after vaccination against COVID-19 must be assessed by taking the risk of infection and symptoms following COVID-19 infection into account.
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Affiliation(s)
- Selina Kikkenborg Berg
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Helle Wallach-Kildemoes
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Line Ryberg Rasmussen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Ulrikka Nygaard
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
- Department of Paediatrics and Adolescents Medicine, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Nina Marie Birk
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Annette Kjær Ersbøll
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, 1455 Copenhagen, Denmark
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, 1455 Copenhagen, Denmark
| | - Susanne Dam Nielsen
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
- Department of Infectious Disease, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Anne Vinggaard Christensen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
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Varga AN, Guevara Morel AE, Lokkerbol J, van Dongen JM, van Tulder MW, Bosmans JE. Dealing with confounding in observational studies: A scoping review of methods evaluated in simulation studies with single-point exposure. Stat Med 2023; 42:487-516. [PMID: 36562408 PMCID: PMC10107671 DOI: 10.1002/sim.9628] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/22/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
The aim of this article was to perform a scoping review of methods available for dealing with confounding when analyzing the effect of health care treatments with single-point exposure in observational data. We aim to provide an overview of methods and their performance assessed by simulation studies indexed in PubMed. We searched PubMed for simulation studies published until January 2021. Our search was restricted to studies evaluating binary treatments and binary and/or continuous outcomes. Information was extracted on the methods' assumptions, performance, and technical properties. Of 28,548 identified references, 127 studies were eligible for inclusion. Of them, 84 assessed 14 different methods (ie, groups of estimators that share assumptions and implementation) for dealing with measured confounding, and 43 assessed 10 different methods for dealing with unmeasured confounding. Results suggest that there are large differences in performance between methods and that the performance of a specific method is highly dependent on the estimator. Furthermore, the methods' assumptions regarding the specific data features also substantially influence the methods' performance. Finally, the methods result in different estimands (ie, target of inference), which can even vary within methods. In conclusion, when choosing a method to adjust for measured or unmeasured confounding it is important to choose the most appropriate estimand, while considering the population of interest, data structure, and whether the plausibility of the methods' required assumptions hold.
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Affiliation(s)
- Anita Natalia Varga
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
| | - Alejandra Elizabeth Guevara Morel
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
| | - Joran Lokkerbol
- Centre of Economic Evaluation, Trimbos Institute (Netherlands Institute of Mental Health), Utrecht, The Netherlands
| | - Johanna Maria van Dongen
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
| | - Maurits Willem van Tulder
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands.,Department Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Judith Ekkina Bosmans
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
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Streeter AJ, Rodgers LR, Hamilton F, Masoli JAH, Blé A, Hamilton WT, Henley WE. Influenza vaccination reduced myocardial infarctions in United Kingdom older adults: a prior event rate ratio study. J Clin Epidemiol 2022; 151:122-131. [PMID: 35817230 DOI: 10.1016/j.jclinepi.2022.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVES We aimed to estimate the real-world effectiveness of the influenza vaccine against myocardial infarction (MI) and influenza in the decade since adults aged ≥ 65 years were first recommended the vaccine. STUDY DESIGN AND SETTING We identified annual cohorts, 1997 to 2011, of adults aged ≥ 65 years, without previous influenza vaccination, from UK general practices, registered with the Clinical Practice Research Datalink. Using a quasi-experimental study design to control for confounding bias, we estimated influenza vaccine effectiveness on hospitalization for MI, influenza, and antibiotic prescriptions for lower respiratory tract infections. RESULTS Vaccination was moderately effective against influenza, the prior event rate ratio-adjusted hazard ratios ranging from 0.70 in 1999 to 0.99 in 2001. Prior event rate ratio-adjusted hazard ratios demonstrated a protective effect against MIs, varying between 0.40 in 2010 and 0.89 in 2001. Aggregated across the cohorts, influenza vaccination reduced the risk of MIs by 39% (95% confidence interval: 34%, 44%). CONCLUSION Effectiveness of the flu vaccine in preventing MIs in older UK adults is consistent with the limited evidence from clinical trials. Similar trends in effectiveness against influenza and against MIs suggest the risk of influenza mediates the effectiveness against MIs, although divergence in some years implies the mechanism may be complex.
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Affiliation(s)
- Adam J Streeter
- Institute for Epidemiology and Social Medicine, University of Münster, Münster, North Rhine-Westphalia, Germany; Medical Statistics, Faculty of Health, University of Plymouth, Plymouth Science Park, Derriford, Plymouth, UK; Health Statistics Group, University of Exeter Medical School, University of Exeter, South Cloisters, St. Luke's Campus, Exeter, UK.
| | - Lauren R Rodgers
- Health Statistics Group, University of Exeter Medical School, University of Exeter, South Cloisters, St. Luke's Campus, Exeter, UK
| | - Fergus Hamilton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol BS8 2PS, UK
| | - Jane A H Masoli
- College of Medicine and Health, University of Exeter Medical School, St. Luke's Campus, Exeter, UK; Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Alessandro Blé
- College of Medicine and Health, University of Exeter Medical School, St. Luke's Campus, Exeter, UK
| | - William T Hamilton
- College of Medicine and Health, University of Exeter Medical School, St. Luke's Campus, Exeter, UK
| | - William E Henley
- Health Statistics Group, University of Exeter Medical School, University of Exeter, South Cloisters, St. Luke's Campus, Exeter, UK
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Kim J, Lesko CR, Fojo AT, Keruly JC, Moore RD, Chander G, Lau B. The Effect of Buprenorphine on Human Immunodeficiency Virus Viral Suppression. Clin Infect Dis 2021; 73:1951-1956. [PMID: 34171087 PMCID: PMC8664419 DOI: 10.1093/cid/ciab578] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Opioid use is prevalent among people living with human immunodeficiency virus (HIV; PLWH) and adversely affects HIV outcomes. We assessed the effect of buprenorphine (BUP) initiation on subsequent HIV viral loads. METHODS We identified PLWH from the Johns Hopkins HIV Clinical Cohort who initiated BUP between 2002 and 2017. Poisson regression with robust variance was used to estimate the prevalence of viral suppression (<200 copies/mL) before and after BUP initiation. We matched individuals who initiated BUP with controls based on viral load measurement dates and used prior event rate ratio (PERR) methods to estimate the effect of BUP initiation on viral suppression. PERR methods account for unmeasured confounders. RESULTS We identified 279 PLWH who initiated BUP. After BUP initiation, PLWH were more likely to be virally suppressed (prevalence ratio [PR], 1.19; 95% confidence interval [CI], 1.03-1.37). After matching PLWH who initiated BUP to controls and accounting for measured and unmeasured confounders, BUP initiation increased viral suppression for both those on antiretroviral therapy (ART) at baseline (PERR PR, 1.08; 95% CI, 1.00-1.18) and those not on ART at baseline (PR, 1.31; 95% CI, 1.10-1.61). CONCLUSIONS Our results indicate that the initiation of BUP results in an increase in the probability of being virally suppressed after accounting for both measured and unmeasured confounders. Persons with opioid use disorder should initiate BUP to not only treat substance use but also to increase viral suppression allowing for treatment as prevention.
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Affiliation(s)
- Jongyeon Kim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anthony T Fojo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeanne C Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Geetanjali Chander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Moriarty F, Thompson W, Boland F. Methods for evaluating the benefit and harms of deprescribing in observational research using routinely collected data. Res Social Adm Pharm 2021; 18:2269-2275. [PMID: 34034959 DOI: 10.1016/j.sapharm.2021.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/09/2021] [Accepted: 05/12/2021] [Indexed: 12/17/2022]
Abstract
Deprescribing is defined as "the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit". Barriers to deprescribing include healthcare professional fear and lack of guidance. These may stem from limited available evidence on benefits and harms of deprescribing medications commonly used among older persons. Advances in pharmacoepidemiology and causal inference methods to evaluate comparative effectiveness and safety of prescribing medications have yet to be considered for deprescribing medication. This paper discusses select methods and how they can be applied to deprescribing research, using case studies of benzodiazepines and low-dose acetylsalicylic acid (aspirin). Target trial emulation involves the explicit application of design principles from randomised controlled trials to observational studies. Several design aspects, including defining eligibility criteria and time zero, require additional considerations for deprescribing studies. The active comparator new user design also presents challenges, including selection of an appropriate comparator. This paper discusses these aspects, and others, in relation to deprescribing studies. Furthermore, methods proposed to control for confounding, in particular, the prior event rate ratio and propensity scores, are discussed. Introduction of billing codes or mechanisms for accurately determining when deprescribing has occurred would enhance the ability to conduct research using routinely collected data. Although the approaches discussed in this paper may strengthen observational studies of deprescribing, their use may be best suited to certain scenarios or research questions, where randomised controlled trials may be less feasible.
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Affiliation(s)
- Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland.
| | - Wade Thompson
- Women's College Hospital Research Institute, Toronto, Ontario, Canada
| | - Fiona Boland
- Data Science Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Rodgers LR, Streeter AJ, Lin N, Hamilton W, Henley WE. Impact of influenza vaccination on amoxicillin prescriptions in older adults: A retrospective cohort study using primary care data. PLoS One 2021; 16:e0246156. [PMID: 33513169 PMCID: PMC7846013 DOI: 10.1371/journal.pone.0246156] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/15/2021] [Indexed: 11/18/2022] Open
Abstract
Background Bacterial infections of the upper and lower respiratory tract are a frequent complication of influenza and contribute to the widespread use of antibiotics. Influenza vaccination may help reduce both appropriate and inappropriate prescribing of antibiotics. Electronic health records provide a rich source of information for assessing secondary effects of influenza vaccination. Methods We conducted a retrospective study to estimate effects of influenza vaccine on antibiotic (amoxicillin) prescription in the elderly based on data from the Clinical Practice Research Datalink. The introduction of UK policy to recommend the influenza vaccine to older adults in 2000 led to a substantial increase in uptake, creating a natural experiment. Of 259,753 eligible patients that were unvaccinated in 1999 and aged≥65y by January 2000, 88,519 patients received influenza vaccination in 2000. These were propensity score matched 1:1 to unvaccinated patients. Time-to-amoxicillin was analysed using the Prior Event Rate Ratio (PERR) Pairwise method to address bias from time-invariant measured and unmeasured confounders. A simulation study and negative control outcome were used to help strengthen the validity of results. Results Compared to unvaccinated patients, those from the vaccinated group were more likely to be prescribed amoxicillin in the year prior to vaccination: hazard ratio (HR) 1.90 (95% confidence interval 1.83, 1.98). Following vaccination, the vaccinated group were again more likely to be prescribed amoxicillin, HR 1.64 (1.58,1.71). After adjusting for prior differences between the two groups using PERR Pairwise, overall vaccine effectiveness was 0.86 (0.81, 0.92). Additional analyses suggested that provided data meet the PERR assumptions, these estimates were robust. Conclusions Once differences between groups were taken into account, influenza vaccine had a beneficial effect, lowering the frequency of amoxicillin prescribing in the vaccinated group. Ensuring successful implementation of national programmes of vaccinating older adults against influenza may help contribute to reducing antibiotic resistance.
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Affiliation(s)
- Lauren R. Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
- * E-mail:
| | - Adam J. Streeter
- Medical Statistics, Faculty of Health: Medicine, Dentistry & Human Sciences, University of Plymouth, Plymouth, United Kingdom
| | - Nan Lin
- Department of Mathematics, Physics and Electrical Engineering, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Willie Hamilton
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
| | - William E. Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
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van Aalst R, Thommes E, Postma M, Chit A, Dahabreh IJ. On the Causal Interpretation of Rate-Change Methods: The Prior Event Rate Ratio and Rate Difference. Am J Epidemiol 2021; 190:142-149. [PMID: 32596726 PMCID: PMC7784529 DOI: 10.1093/aje/kwaa122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/17/2022] Open
Abstract
A growing number of studies use data before and after treatment initiation in groups exposed to different treatment strategies to estimate “causal effects” using a ratio measure called the prior event rate ratio (PERR). Here, we offer a causal interpretation for PERR and its additive scale analog, the prior event rate difference (PERD). We show that causal interpretation of these measures requires untestable rate-change assumptions about the relationship between 1) the change of the counterfactual rate before and after treatment initiation in the treated group under hypothetical intervention to implement the control strategy; and 2) the change of the factual rate before and after treatment initiation in the control group. The rate-change assumption is on the multiplicative scale for PERR but on the additive scale for PERD; the 2 assumptions hold simultaneously under testable, but unlikely, conditions. Even if investigators can pick the most appropriate scale, the relevant rate-change assumption might not hold exactly, so we describe sensitivity analysis methods to examine how assumption violations of different magnitudes would affect study results. We illustrate the methods using data from a published study of proton pump inhibitors and pneumonia.
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Affiliation(s)
- Robertus van Aalst
- Correspondence to Dr. Robertus van Aalst, Sanofi Pasteur, 1 Discovery Drive, Swiftwater, PA 18370 (e-mail: )
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11
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Evaluating the Relative Vaccine Effectiveness of Adjuvanted Trivalent Influenza Vaccine Compared to High-Dose Trivalent and Other Egg-Based Influenza Vaccines among Older Adults in the US during the 2017-2018 Influenza Season. Vaccines (Basel) 2020; 8:vaccines8030446. [PMID: 32784684 PMCID: PMC7563546 DOI: 10.3390/vaccines8030446] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/02/2020] [Accepted: 08/03/2020] [Indexed: 12/11/2022] Open
Abstract
The influenza-related disease burden is highest among the elderly. We evaluated the relative vaccine effectiveness (rVE) of adjuvanted trivalent influenza vaccine (aTIV) compared to other egg-based influenza vaccines (high-dose trivalent (TIV-HD), quadrivalent (QIVe-SD), and standard-dose trivalent (TIVe-SD)) against influenza-related and cardio-respiratory events among subjects aged ≥65 years for the 2017–2018 influenza season. This retrospective cohort analysis used prescription claims, professional fee claims, and hospital charge master data. Influenza-related hospitalizations/ER visits and office visits and cardio-respiratory events were assessed post-vaccination. Inverse probability of treatment weighting (IPTW) and Poisson regression were used to evaluate the adjusted rVE of aTIV compared to other vaccines. In an economic analysis, annualized follow-up costs were compared between aTIV and TIV-HD. The study was composed of 234,313 aTIV, 1,269,855 TIV-HD, 212,287 QIVe-SD, and 106,491 TIVe-SD recipients. aTIV was more effective in reducing influenza-related office visits and other respiratory-related hospitalizations/ER visits compared to the other vaccines. For influenza-related hospitalizations/ER visits, aTIV was associated with a significantly higher rVE compared to QIVe-SD and TIVe-SD and was comparable to TIV-HD. aTIV was also associated with a significantly higher rVE compared to TIVe-SD against hospitalizations/ER visits related to pneumonia and asthma/COPD/bronchial events. aTIV and TIV-HD were associated with comparable annualized all-cause and influenza-related costs. Adjusted analyses demonstrated a significant benefit of aTIV against influenza- and respiratory-related events compared to the other egg-based vaccines.
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12
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Rodgers LR, Dennis JM, Shields BM, Mounce L, Fisher I, Hattersley AT, Henley WE. Prior event rate ratio adjustment produced estimates consistent with randomized trial: a diabetes case study. J Clin Epidemiol 2020; 122:78-86. [PMID: 32194148 PMCID: PMC7262589 DOI: 10.1016/j.jclinepi.2020.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/06/2020] [Accepted: 03/12/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Electronic health records (EHR) provide a valuable resource for assessing drug side-effects, but treatments are not randomly allocated in routine care creating the potential for bias. We conduct a case study using the Prior Event Rate Ratio (PERR) Pairwise method to reduce unmeasured confounding bias in side-effect estimates for two second-line therapies for type 2 diabetes, thiazolidinediones, and sulfonylureas. STUDY DESIGN AND SETTINGS Primary care data were extracted from the Clinical Practice Research Datalink (n = 41,871). We utilized outcomes from the period when patients took first-line metformin to adjust for unmeasured confounding. Estimates for known side-effects and a negative control outcome were compared with the A Diabetes Outcome Progression Trial (ADOPT) trial (n = 2,545). RESULTS When on metformin, patients later prescribed thiazolidinediones had greater risks of edema, HR 95% CI 1.38 (1.13, 1.68) and gastrointestinal side-effects (GI) 1.47 (1.28, 1.68), suggesting the presence of unmeasured confounding. Conventional Cox regression overestimated the risk of edema on thiazolidinediones and identified a false association with GI. The PERR Pairwise estimates were consistent with ADOPT: 1.43 (1.10, 1.83) vs. 1.39 (1.04, 1.86), respectively, for edema, and 0.91 (0.79, 1.05) vs. 0.94 (0.80, 1.10) for GI. CONCLUSION The PERR Pairwise approach offers potential for enhancing postmarketing surveillance of side-effects from EHRs but requires careful consideration of assumptions.
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Affiliation(s)
- Lauren R Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, UK.
| | - John M Dennis
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Beverley M Shields
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - Luke Mounce
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | | | - Andrew T Hattersley
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - William E Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
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13
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Thommes EW, Mahmud SM, Young-Xu Y, Snider JT, van Aalst R, Lee JKH, Halchenko Y, Russo E, Chit A. Assessing the prior event rate ratio method via probabilistic bias analysis on a Bayesian network. Stat Med 2020; 39:639-659. [PMID: 31788843 PMCID: PMC7027899 DOI: 10.1002/sim.8435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/21/2019] [Accepted: 11/03/2019] [Indexed: 12/04/2022]
Abstract
Background: Unmeasured confounders are commonplace in observational studies conducted using real‐world data. Prior event rate ratio (PERR) adjustment is a technique shown to perform well in addressing such confounding. However, it has been demonstrated that, in some circumstances, the PERR method actually increases rather than decreases bias. In this work, we seek to better understand the robustness of PERR adjustment. Methods: We begin with a Bayesian network representation of a generalized observational study, which is subject to unmeasured confounding. Previous work evaluating PERR performance used Monte Carlo simulation to calculate joint probabilities of interest within the study population. Here, we instead use a Bayesian networks framework. Results: Using this streamlined analytic approach, we are able to conduct probabilistic bias analysis (PBA) using large numbers of combinations of parameters and thus obtain a comprehensive picture of PERR performance. We apply our methodology to a recent study that used the PERR in evaluating elderly‐specific high‐dose (HD) influenza vaccine in the US Veterans Affairs population. That study obtained an HD relative effectiveness of 25% (95% CI: 2%‐43%) against influenza‐ and pneumonia‐associated hospitalization, relative to standard‐dose influenza vaccine. In this instance, we find that the PERR‐adjusted result is more like to underestimate rather than to overestimate the relative effectiveness of the intervention. Conclusions: Although the PERR is a powerful tool for mitigating the effects of unmeasured confounders, it is not infallible. Here, we develop some general guidance for when a PERR approach is appropriate and when PBA is a safer option.
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Affiliation(s)
- Edward W Thommes
- Sanofi Pasteur, Swiftwater, Pennsylvania.,Department of Mathematics and Statistics, University of Guelph, Guelph, Ontario, Canada
| | - Salaheddin M Mahmud
- Department of Community Health Sciences, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Yinong Young-Xu
- Clinical Epidemiology Program, Veterans Affairs Medical Center, White River Junction, Vermont.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | | | - Jason K H Lee
- Leslie Dan School of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Sanofi Pasteur, Toronto, Ontario, Canada
| | - Yuliya Halchenko
- Clinical Epidemiology Program, Veterans Affairs Medical Center, White River Junction, Vermont
| | - Ellyn Russo
- Clinical Epidemiology Program, Veterans Affairs Medical Center, White River Junction, Vermont
| | - Ayman Chit
- Sanofi Pasteur, Swiftwater, Pennsylvania.,Leslie Dan School of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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14
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van Aalst R, Gravenstein S, Mor V, Mahmud SM, Wilschut J, Postma M, Chit A. Comparative effectiveness of high dose versus adjuvanted influenza vaccine: A retrospective cohort study. Vaccine 2019; 38:372-379. [PMID: 31606249 DOI: 10.1016/j.vaccine.2019.09.105] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Adults 65 years and older (seniors) experience more complications following influenza infection than younger adults. We estimated the relative vaccine effectiveness (rVE) of a trivalent high dose (HD-IIV3) versus an adjuvanted trivalent influenza vaccine (aIIV3) in seniors for respiratory-related hospitalizations. METHODS We conducted a retrospective cohort study using claims data from Optum's Clinformatics® Data Mart to compare outcome rates between seniors who received HD-IIV3 versus aIIV3 during the 2016/17 and 2017/18, predominantly A/H3N2 respiratory seasons. Rates were adjusted for demographic characteristics, comorbid conditions, previous influenza vaccination, and geography. We used the previous event rate ratio (PERR) approach to address bias by time-fixed unmeasured confounders. RESULTS We identified 842,282 HD-IIV3 and 34,157 aIIV3 recipients for the 2016/17 season and 1,058,638 HD-IIV3 and 189,636 aIIV3 recipients for the 2017/18 season. The pooled rVE of HD-IIV3 versus aIIV3 for respiratory-related hospitalizations over both seasons was 12% (95% confidence interval: 3.3%-20%); 13% (-6.4% to 32%) for the 2016/17 season and 12% (2.1%-21%) for the 2017/18 season. CONCLUSIONS Pooled over two predominantly A/H3N2 respiratory seasons, HD-IIV3 was associated with fewer respiratory hospital admissions than aIIV3 in senior members of large national managed health care company in the U.S.
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Affiliation(s)
- Robertus van Aalst
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Vaccine Epidemiology and Modelling, Sanofi Pasteur, Swiftwater, PA, USA.
| | - Stefan Gravenstein
- Brown University, School of Public Health, Dept. Health Services, Policy and Practice, USA; Providence VA Medical Center, Center of Long-Term Services and Support, USA; Center for Gerontology & Healthcare Research, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Vincent Mor
- Brown University, School of Public Health, Dept. Health Services, Policy and Practice, USA; Providence VA Medical Center, Center of Long-Term Services and Support, USA
| | - Salaheddin M Mahmud
- Department of Community Health Sciences, College of Medicine, University of Manitoba, Winnipeg, MB, Canada; George & Fay Yee Center for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Jan Wilschut
- Department of Medical Microbiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Maarten Postma
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Unit of PharmacoTherapy, -Epidemiology & -Economics (PTE2), University of Groningen, Department of Pharmacy, Groningen, the Netherlands; Department of Economics, Econometrics & Finance, University of Groningen, Faculty of Economics & Business, Groningen, the Netherlands
| | - Ayman Chit
- Vaccine Epidemiology and Modelling, Sanofi Pasteur, Swiftwater, PA, USA; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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15
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Sommet A, Pariente A. Methods in pharmacoepidemiology. Therapie 2019; 74:187-197. [PMID: 30819408 DOI: 10.1016/j.therap.2018.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/26/2018] [Indexed: 01/04/2023]
Abstract
Pharmacoepidemiology is the study of interactions between drugs and human populations, investigating, in real conditions of life, benefits, risks and use of drugs. Pharmacoepidemiology applies to drugs and their pharmacological evaluations, the different methods also used in epidemiology to assess in real conditions of life, benefits, risks and use of drugs. Pharmacoepidemiologic studies are ad-hoc studies or studies on databases. Specific methods exist to measure drug exposure, as well as indicators of compliance and misuse of drugs. Various designs for descriptive and explanatory studies exist, in a context in which a growing proportion of studies are carried out using medico-administrative data. The limits traditionally affecting the study designs are modified in this context, almost any design selected for the conduct of a study from these databases then deriving from a cohort in whom the information has been recorded prospectively and exhaustively.
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Affiliation(s)
- Agnès Sommet
- Service de pharmacologie médicale et clinique, UMR Inserm 1027, CIC Inserm 1436, faculté de médecine, centre hospitalier universitaire, 31000 Toulouse, France.
| | - Antoine Pariente
- Inserm, Bordeaux population health research centre, team pharmacoepidemiology, UMR 1219, university of Bordeaux, 33076 Bordeaux, France; Pôle de santé publique, centre régional de pharmacovigilance de Bordeaux, service de pharmacologie médicale, CHU de Bordeaux, 33076 Bordeaux, France
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16
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Zirk‐Sadowski J, Masoli JA, Delgado J, Hamilton W, Strain WD, Henley W, Melzer D, Ble A. Proton-Pump Inhibitors and Long-Term Risk of Community-Acquired Pneumonia in Older Adults. J Am Geriatr Soc 2018; 66:1332-1338. [PMID: 29676433 PMCID: PMC6099478 DOI: 10.1111/jgs.15385] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 02/16/2018] [Accepted: 02/28/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To estimate associations between long-term use of proton pump inhibitors (PPIs) and pneumonia incidence in older adults in primary care. DESIGN Longitudinal analyses of electronic medical records. SETTING England PARTICIPANTS: Individuals aged 60 and older in primary care receiving PPIs for 1 year or longer (N=75,050) and age- and sex-matched controls (N=75,050). MEASUREMENTS Net hazard ratios for pneumonia incidence in Year 2 of treatment were estimated using the prior event rate ratio (PERR), which adjusts for pneumonia incidence differences before initiation of treatment. Inverse probability weighted models adjusted for 78 demographic, disease, medication, and healthcare usage measures. RESULTS During the second year after initiating treatment, PPIs were associated with greater hazard of incident pneumonia (PERR-adjusted hazard ratio=1.82, 95% confidence interval=1.27-2.54), accounting for pretreatment pneumonia rates. Estimates were similar across age and comorbidity subgroups. Similar results were also obtained from propensity score- and inverse probability-weighted models. CONCLUSION In a large cohort of older adults in primary care, PPI prescription was associated with greater risk of pneumonia in the second year of treatment. Results were robust across alternative analysis approaches. Controversies about the validity of reported short-term harms of PPIs should not divert attention from potential long-term effects of PPI prescriptions on older adults.
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Affiliation(s)
- Jan Zirk‐Sadowski
- Epidemiology and Public Health Group, Medical SchoolUniversity of ExeterExeterUnited Kingdom
- Medicines Policy Research Unit, Centre for Big Data Research in HealthUniversity of New South WalesSydneyAustralia
| | - Jane A. Masoli
- Epidemiology and Public Health Group, Medical SchoolUniversity of ExeterExeterUnited Kingdom
- Department of Healthcare for Older PeopleRoyal Devon and Exeter National Health Service Foundation TrustExeterUnited Kingdom
| | - Joao Delgado
- Epidemiology and Public Health Group, Medical SchoolUniversity of ExeterExeterUnited Kingdom
| | - Willie Hamilton
- Primary Care Diagnostics, Medical School, St Luke's CampusUniversity of ExeterExeterUnited Kingdom
| | - W. David Strain
- Department of Healthcare for Older PeopleRoyal Devon and Exeter National Health Service Foundation TrustExeterUnited Kingdom
- Diabetes and Vascular Medicine, Medical SchoolUniversity of ExeterExeterUnited Kingdom
| | - William Henley
- Health Statistics Group, Institute of Health Research, Medical School, St Luke's CampusUniversity of ExeterExeterUnited Kingdom
| | - David Melzer
- Epidemiology and Public Health Group, Medical SchoolUniversity of ExeterExeterUnited Kingdom
| | - Alessandro Ble
- Epidemiology and Public Health Group, Medical SchoolUniversity of ExeterExeterUnited Kingdom
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17
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Brophy S, Kennedy J, Fernandez-Gutierrez F, John A, Potter R, Linehan C, Kerr M. Characteristics of Children Prescribed Antipsychotics: Analysis of Routinely Collected Data. J Child Adolesc Psychopharmacol 2018; 28:180-191. [PMID: 29486137 PMCID: PMC5905863 DOI: 10.1089/cap.2017.0003] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Antipsychotics are licensed for psychosis and are also prescribed for behavior control. This study aims to examine characteristics and outcomes of children prescribed antipsychotics. METHODS A cohort study using general practice and hospital records linked with education records for 1,488,936 children living in Wales between 1999 and 2015. The characteristics of the children who were prescribed antipsychotics are presented using descriptive statistics and outcomes such as respiratory illness, diabetes, and injury were analyzed using multilevel logistic regression and the prior event rate ratio (PERR). RESULTS Children with intellectual difficulty/autism were more likely to be prescribed antipsychotics (2.8% have been prescribed an antipsychotic [75% with autism] compared with 0.15% of children without intellectual difficulty). Those with intellectual disabilities/autism were prescribed antipsychotics at a younger age and for a longer period. Antipsychotic use was associated with a higher rate of respiratory illness for all (PERR of hospital admission: 1.55 [95% CI: 1.51-1.598] or increase in rate of 2 per 100 per year in those treated), and for those with intellectual difficulty/autism, there was a higher rate of injury and hospitalized depression. However, among those without intellectual difficulty/autism, there were lower rates of depression (PERR: 0.55 [95% CI: 0.51-0.59]). CONCLUSIONS This work shows real-world use of antipsychotics and provides information on the rate of possible adverse events in children treated. Antipsychotics are predominantly used for those with intellectual difficulty/autism rather than those with a psychotic diagnosis. There is evidence that rates of respiratory disease, epilepsy, and diabetes are also higher postantipsychotic use for all. In those with intellectual difficulty/autism, hospital-admitted depression and injury are higher postantipsychotic use. The use of antipsychotics for behavioral management is likely to have increased cost implications to the healthcare system.
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Affiliation(s)
- Sinead Brophy
- FARR Institute (CIPHER), Swansea University Medical School, Swansea, United Kingdom
| | - Jonathan Kennedy
- FARR Institute (CIPHER), Swansea University Medical School, Swansea, United Kingdom
| | | | - Ann John
- Population Psychiatry, Suicide and Informatics, FARR Institute (CIPHER), Swansea University Medical School, Swansea, United Kingdom
| | - Robert Potter
- Cwm Taf Health University Health Board and Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University School of Medicine, Cardiff, Wales
| | - Christine Linehan
- UCD Centre for Disability Studies, University College Dublin, Dublin, Ireland
| | - Michael Kerr
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University School of Medicine, Cardiff, Wales
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Pariente A, Mansiaux Y, Jarné A, Salvo F, Pageot C, Bezin J, Smith A, Bégaud B. Impact of pioglitazone regulatory withdrawal on antidiabetic drug use and health in diabetic patients. Eur J Clin Pharmacol 2017; 73:1655-1663. [DOI: 10.1007/s00228-017-2326-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 08/22/2017] [Indexed: 11/25/2022]
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Zirk-Sadowski J, Masoli JA, Strain WD, Delgado J, Henley W, Hamilton W, Melzer D, Ble A. Proton-Pump Inhibitors and Fragility Fractures in Vulnerable Older Patients. Am J Gastroenterol 2017; 112:520-523. [PMID: 28270664 PMCID: PMC5350542 DOI: 10.1038/ajg.2016.584] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Jan Zirk-Sadowski
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Jane A Masoli
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - W David Strain
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Joao Delgado
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - William Henley
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Willy Hamilton
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - David Melzer
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Alessandro Ble
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK,Epidemiology and Public Health, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK. E-mail:
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20
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Reynolds RF, Kurz X, de Groot MCH, Schlienger RG, Grimaldi-Bensouda L, Tcherny-Lessenot S, Klungel OH. The IMI PROTECT project: purpose, organizational structure, and procedures. Pharmacoepidemiol Drug Saf 2017; 25 Suppl 1:5-10. [PMID: 27038353 DOI: 10.1002/pds.3933] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 12/13/2022]
Abstract
The Pharmacoepidemiological Research on Outcomes of Therapeutics by a European ConsorTium (PROTECT) initiative was a collaborative European project that sought to address limitations of current methods in the field of pharmacoepidemiology and pharmacovigilance. Initiated in 2009 and ending in 2015, PROTECT was part of the Innovative Medicines Initiative, a joint undertaking by the European Union and pharmaceutical industry. Thirty-five partners including academics, regulators, small and medium enterprises, and European Federation of Pharmaceuticals Industries and Associations companies contributed to PROTECT. Two work packages within PROTECT implemented research examining the extent to which differences in the study design, methodology, and choice of data source can contribute to producing discrepant results from observational studies on drug safety. To evaluate the effect of these differences, the project applied different designs and analytic methodology for six drug-adverse event pairs across several electronic healthcare databases and registries. This papers introduces the organizational structure and procedures of PROTECT, including how drug-adverse event and data sources were selected, study design and analyses documents were developed, and results managed centrally.
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Affiliation(s)
| | | | - Mark C H de Groot
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands.,Department of Clinical Chemistry and Haematology, Division of Laboratory and Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | | | - Olaf H Klungel
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
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21
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Dennis M, Shine L, John A, Marchant A, McGregor J, Lyons RA, Brophy S. Risk of Adverse Outcomes for Older People with Dementia Prescribed Antipsychotic Medication: A Population Based e-Cohort Study. Neurol Ther 2017; 6:57-77. [PMID: 28054240 PMCID: PMC5447553 DOI: 10.1007/s40120-016-0060-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Over recent years there has been growing evidence of increased risk of mortality associated with antipsychotic use in older people with dementia. Although this concern combined with limited evidence of efficacy has informed guidelines restricting antipsychotic prescription in this population, the use of antipsycotics remains common. Many published studies only report short-term outcomes, are restricted to examining mortality and stroke risk or have other limitations. The aim of this study was to assess adverse outcomes associated with the use of antipsychotics in older people living with dementia in Wales (UK). METHODS This was a retrospective study of a population-based dementia cohort using the Welsh Secure Anonymised Information Linkage databank. The prior event rate ratio (PERR) was used to estimate the influence of exposure to antipsychotic medication on acute cardiac events, venous thromboembolism, stroke and hip fracture, and adjusted Cox proportional hazard models were used to compare all-cause mortality. RESULTS A total of 10,339 people aged ≥65 years were identified with newly diagnosed dementia. After excluding those who did not meet the inclusion criteria, 9674 people remained in the main cohort of whom 3735 were exposed to antipsychotic medication. An increased risk of a venous thromboembolic episode [PERR 1.95, 95% confidence interval (CI) 1.83-2.0], stroke (PERR 1.41, 95% CI 1.4-1.46) and hip fracture (PERR 1.62, 95% CI 1.59-1.65) was associated with antipsychotic use. However, there was no long-term increased mortality in people exposed to antipsychotics (adjusted hazard ratio 1.06, 95% CI 0.99-1.13). CONCLUSIONS The increase in adverse medical events supports guidelines restricting antipsychotic use in this population.
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Affiliation(s)
- Michael Dennis
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK.
| | - Laura Shine
- Cwm Taf Health Board, Port Talbot, Wales, UK
| | - Ann John
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Amanda Marchant
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Joanna McGregor
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Ronan A Lyons
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Sinead Brophy
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
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22
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Othman F, Crooks CJ, Card TR. Community acquired pneumonia incidence before and after proton pump inhibitor prescription: population based study. BMJ 2016; 355:i5813. [PMID: 28715344 PMCID: PMC5110150 DOI: 10.1136/bmj.i5813] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2016] [Indexed: 01/01/2023]
Abstract
Objective To examine the risk of community acquired pneumonia before and after prescription of proton pump inhibitor (PPI) and assess whether unmeasured confounding explains this association.Design Cohort study and self controlled case series.Setting Clinical Practice Research Datalink (1990 to 2013) in UK.Participants Adult patients with a new prescription for a PPI individually matched with controls.Main outcome measures Association of community acquired pneumonia with PPI prescription estimated by three methods: a multivariable Cox model comparing risk in PPI exposed patients with controls, corrected for potential confounders; a self controlled case series; and a prior event rate ratio (PERR) analysis over the 12 month periods before and after the first PPI prescription.Results 160 000 new PPI users were examined. The adjusted Cox regression showed a risk of community acquired pneumonia 1.67 (95% confidence interval 1.55 to 1.79) times higher for patients exposed to PPI than for controls. In the self controlled case series, among 48 451 PPI exposed patients with a record of community acquired pneumonia, the incidence rate ratio was 1.19 (95% confidence interval 1.14 to 1.25) in the 30 days after PPI prescription but was higher in the 30 days before a PPI prescription (1.92, 1.84 to 2.00). The Cox regressions for prior event rate ratio similarly showed a greater increase in community acquired pneumonia in the year before than the year after PPI prescription, such that the analysis showed a reduced relative risk of pneumonia associated with PPI use (prior event rate ratio 0.91, 95% confidence interval 0.83 to 0.99).Conclusion The association between the use of PPIs and risk of community acquired pneumonia is likely to be due entirely to confounding factors.
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Affiliation(s)
- Fatmah Othman
- Department of Epidemiology and Public Health, University of Nottingham, Nottingham NG5 1PB, UK
- Department of Basic Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia
| | - Colin J Crooks
- Department of Epidemiology and Public Health, University of Nottingham, Nottingham NG5 1PB, UK
| | - Timothy R Card
- Department of Epidemiology and Public Health, University of Nottingham, Nottingham NG5 1PB, UK
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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23
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Lin NX, Henley WE. Prior event rate ratio adjustment for hidden confounding in observational studies of treatment effectiveness: a pairwise Cox likelihood approach. Stat Med 2016; 35:5149-5169. [PMID: 27477530 PMCID: PMC5111612 DOI: 10.1002/sim.7051] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 06/23/2016] [Accepted: 07/01/2016] [Indexed: 11/06/2022]
Abstract
Observational studies provide a rich source of information for assessing effectiveness of treatment interventions in many situations where it is not ethical or practical to perform randomized controlled trials. However, such studies are prone to bias from hidden (unmeasured) confounding. A promising approach to identifying and reducing the impact of unmeasured confounding is prior event rate ratio (PERR) adjustment, a quasi-experimental analytic method proposed in the context of electronic medical record database studies. In this paper, we present a statistical framework for using a pairwise approach to PERR adjustment that removes bias inherent in the original PERR method. A flexible pairwise Cox likelihood function is derived and used to demonstrate the consistency of the simple and convenient alternative PERR (PERR-ALT) estimator. We show how to estimate standard errors and confidence intervals for treatment effect estimates based on the observed information and provide R code to illustrate how to implement the method. Assumptions required for the pairwise approach (as well as PERR) are clarified, and the consequences of model misspecification are explored. Our results confirm the need for researchers to consider carefully the suitability of the method in the context of each problem. Extensions of the pairwise likelihood to more complex designs involving time-varying covariates or more than two periods are considered. We illustrate the application of the method using data from a longitudinal cohort study of enzyme replacement therapy for lysosomal storage disorders. © 2016 The Authors. Statistics in Medicine Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Nan Xuan Lin
- Department of Mathematics and Information Sciences, Northumbria University, Newcastle upon Tyne, NE2 1XE, U.K.,Health Statistics Group, Institute of Health Research, University of Exeter Medical School, Exeter, EX1 2LU, U.K
| | - William Edward Henley
- Health Statistics Group, Institute of Health Research, University of Exeter Medical School, Exeter, EX1 2LU, U.K..
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24
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Uddin MJ, Groenwold RHH, Ali MS, de Boer A, Roes KCB, Chowdhury MAB, Klungel OH. Methods to control for unmeasured confounding in pharmacoepidemiology: an overview. Int J Clin Pharm 2016; 38:714-23. [PMID: 27091131 DOI: 10.1007/s11096-016-0299-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 04/04/2016] [Indexed: 12/21/2022]
Abstract
Background Unmeasured confounding is one of the principal problems in pharmacoepidemiologic studies. Several methods have been proposed to detect or control for unmeasured confounding either at the study design phase or the data analysis phase. Aim of the Review To provide an overview of commonly used methods to detect or control for unmeasured confounding and to provide recommendations for proper application in pharmacoepidemiology. Methods/Results Methods to control for unmeasured confounding in the design phase of a study are case only designs (e.g., case-crossover, case-time control, self-controlled case series) and the prior event rate ratio adjustment method. Methods that can be applied in the data analysis phase include, negative control method, perturbation variable method, instrumental variable methods, sensitivity analysis, and ecological analysis. A separate group of methods are those in which additional information on confounders is collected from a substudy. The latter group includes external adjustment, propensity score calibration, two-stage sampling, and multiple imputation. Conclusion As the performance and application of the methods to handle unmeasured confounding may differ across studies and across databases, we stress the importance of using both statistical evidence and substantial clinical knowledge for interpretation of the study results.
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Affiliation(s)
- Md Jamal Uddin
- Department of Statistics (Biostatistics and Epidemiology), Shahjalal University of Science and Technology, Sylhet, 3114, Bangladesh. .,Division of Pharmacoepidemiology and Clinical Pharmacology, University of Utrecht, Utrecht, The Netherlands.
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mohammed Sanni Ali
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, University of Utrecht, Utrecht, The Netherlands
| | - Kit C B Roes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Muhammad A B Chowdhury
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, University of Utrecht, Utrecht, The Netherlands
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