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Iorio A, Sinagra G, Di Lenarda A. Administrative database, observational research and the Tower of Babel. Int J Cardiol 2019; 284:118-119. [PMID: 30558991 DOI: 10.1016/j.ijcard.2018.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 12/03/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Annamaria Iorio
- Cardiovascular Center, University Hospital and Health Services, Trieste, Italy; Cardiology Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Gianfranco Sinagra
- Cardiovascular Center, University Hospital and Health Services, Trieste, Italy.
| | - Andrea Di Lenarda
- Cardiovascular Center, University Hospital and Health Services, Trieste, Italy.
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Tognoni G, Franzosi MG, Garattini S. Embedding patient- and public health-oriented research in a national health service: the GISSI experience. J R Soc Med 2019; 112:200-204. [PMID: 31074337 PMCID: PMC6512170 DOI: 10.1177/0141076819844934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Gianni Tognoni
- IRCCS Istituto di Ricerche Farmacologiche, ‘Mario
Negri’, Milan 20156, Italy
| | | | - Silvio Garattini
- IRCCS Istituto di Ricerche Farmacologiche, ‘Mario
Negri’, Milan 20156, Italy
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Lauer MS, Gordon D, Wei G, Pearson G. Efficient design of clinical trials and epidemiological research: is it possible? Nat Rev Cardiol 2017; 14:493-501. [PMID: 28447664 DOI: 10.1038/nrcardio.2017.60] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Randomized clinical trials and large-scale, cohort studies continue to have a critical role in generating evidence in cardiovascular medicine; however, the increasing concern is that ballooning costs threaten the clinical trial enterprise. In this Perspectives article, we discuss the changing landscape of clinical research, and clinical trials in particular, focusing on reasons for the increasing costs and inefficiencies. These reasons include excessively complex design, overly restrictive inclusion and exclusion criteria, burdensome regulations, excessive source-data verification, and concerns about the effect of clinical research conduct on workflow. Thought leaders have called on the clinical research community to consider alternative, transformative business models, including those models that focus on simplicity and leveraging of digital resources. We present some examples of innovative approaches by which some investigators have successfully conducted large-scale, clinical trials at relatively low cost. These examples include randomized registry trials, cluster-randomized trials, adaptive trials, and trials that are fully embedded within digital clinical care or administrative platforms.
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Affiliation(s)
- Michael S Lauer
- National Institutes of Health Office of Extramural Research, One Center Drive, Building 1, Room 144, Bethesda, Maryland 20892, USA
| | - David Gordon
- Division of Cardiovascular Sciences of the National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, 8th Floor, Bethesda, Maryland 20892, USA
| | - Gina Wei
- Division of Cardiovascular Sciences of the National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, 8th Floor, Bethesda, Maryland 20892, USA
| | - Gail Pearson
- Division of Cardiovascular Sciences of the National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, 8th Floor, Bethesda, Maryland 20892, USA
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Affiliation(s)
- John J Ryan
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City (J.J.R.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (J.D.R.); Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.A.M.); and Department of Cardiology, Boston VA Heathcare System, Boston, MA (B.A.M.).
| | - Jonathan D Rich
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City (J.J.R.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (J.D.R.); Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.A.M.); and Department of Cardiology, Boston VA Heathcare System, Boston, MA (B.A.M.)
| | - Bradley A Maron
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City (J.J.R.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (J.D.R.); Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.A.M.); and Department of Cardiology, Boston VA Heathcare System, Boston, MA (B.A.M.)
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Affiliation(s)
- Michael S Lauer
- Division of Cardiovascular Sciences (DCVS), National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD, USA
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Lauer MS. Commentary: How the debate about comparative effectiveness research should impact the future of clinical trials. Stat Med 2013; 31:3051-3. [PMID: 23055180 DOI: 10.1002/sim.5400] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Comparative effectiveness research represents the kind of research that arguably more directly affects clinical practice and policy. It includes observational studies, clinical trials, and systematic syntheses of existing literature. In this commentary, I argue for the ongoing and critical role of randomization in comparative effectiveness, noting the key differences between practical and explanatory trials.
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Affiliation(s)
- Michael S Lauer
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA.
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Lauer MS. From hot hands to declining effects: the risks of small numbers. J Am Coll Cardiol 2012; 60:72-4. [PMID: 22742403 DOI: 10.1016/j.jacc.2012.02.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 02/20/2012] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
Abstract
About 25 years ago, a group of researchers demonstrated that there is no such thing as the "hot hand" in professional basketball. When a player hits 5 or 7 shots in a row (or misses 10 in a row), what's at work is random variation, nothing more. However, random causes do not stop players, coaches, fans, and media from talking about and acting on "hot hands," telling stories and making choices that ultimately are based on randomness. The same phenomenon is true in medicine. Some clinical trials with small numbers of events yielded positive findings, which in turn led clinicians, academics, and government officials to talk, telling stories and sometimes making choices that were later shown to be based on randomness. I provide some cardiovascular examples, such as the use of angiotensin receptor blockers for chronic heart failure, nesiritide for acute heart failure, and cytochrome P-450 (CYP) 2C19 genotyping for the acute coronary syndromes. I also review the more general "decline effect," by which drugs appear to yield a lower effect size over time. The decline effect is due at least in part to over interpretation of small studies, which are more likely to be noticed because of publication bias. As funders of research, we at the National Heart, Lung, and Blood Institute seek to support projects that will yield robust, credible evidence that will affect practice and policy in the right way. We must be alert to the risks of small numbers.
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Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG, Latini R, Lucci D, Nicolosi GL, Porcu M, Tognoni G. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. Lancet 2008; 372:1223-30. [PMID: 18757090 DOI: 10.1016/s0140-6736(08)61239-8] [Citation(s) in RCA: 974] [Impact Index Per Article: 60.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Several epidemiological and experimental studies suggest that n-3 polyunsaturated fatty acids (PUFA) can exert favourable effects on atherothrombotic cardiovascular disease, including arrhythmias. We investigated whether n-3 PUFA could improve morbidity and mortality in a large population of patients with symptomatic heart failure of any cause. METHODS We undertook a randomised, double-blind, placebo-controlled trial in 326 cardiology and 31 internal medicine centres in Italy. We enrolled patients with chronic heart failure of New York Heart Association class II-IV, irrespective of cause and left ventricular ejection fraction, and randomly assigned them to n-3 PUFA 1 g daily (n=3494) or placebo (n=3481) by a concealed, computerised telephone randomisation system. Patients were followed up for a median of 3.9 years (IQR 3.0-4.5). Primary endpoints were time to death, and time to death or admission to hospital for cardiovascular reasons. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00336336. FINDINGS We analysed all randomised patients. 955 (27%) patients died from any cause in the n-3 PUFA group and 1014 (29%) in the placebo group (adjusted hazard ratio [HR] 0.91 [95.5% CI 0.833-0.998], p=0.041). 1981 (57%) patients in the n-3 PUFA group and 2053 (59%) in the placebo group died or were admitted to hospital for cardiovascular reasons (adjusted HR 0.92 [99% CI 0.849-0.999], p=0.009). In absolute terms, 56 patients needed to be treated for a median duration of 3.9 years to avoid one death or 44 to avoid one event like death or admission to hospital for cardiovascular reasons. In both groups, gastrointestinal disorders were the most frequent adverse reaction (96 [3%] n-3 PUFA group vs 92 [3%] placebo group). INTERPRETATION A simple and safe treatment with n-3 PUFA can provide a small beneficial advantage in terms of mortality and admission to hospital for cardiovascular reasons in patients with heart failure in a context of usual care.
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Baussano I, Brzoska P, Fedeli U, Larouche C, Razum O, Fung ICH. Does language matter? A case study of epidemiological and public health journals, databases and professional education in French, German and Italian. Emerg Themes Epidemiol 2008; 5:16. [PMID: 18826570 PMCID: PMC2570667 DOI: 10.1186/1742-7622-5-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Accepted: 09/30/2008] [Indexed: 11/30/2022] Open
Abstract
Epidemiology and public health are usually context-specific. Journals published in different languages and countries play a role both as sources of data and as channels through which evidence is incorporated into local public health practice. Databases in these languages facilitate access to relevant journals, and professional education in these languages facilitates the growth of native expertise in epidemiology and public health. However, as English has become the lingua franca of scientific communication in the era of globalisation, many journals published in non-English languages face the difficult dilemma of either switching to English and competing internationally, or sticking to the native tongue and having a restricted circulation among a local readership. This paper discusses the historical development of epidemiology and the current scene of epidemiological and public health journals, databases and professional education in three Western European languages: French, German and Italian, and examines the dynamics and struggles they have today.
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Affiliation(s)
- Iacopo Baussano
- Department of Infectious Disease Epidemiology, St. Mary's Campus, Imperial College London, UK
- CPO-Piemonte, Novara, Italy
| | - Patrick Brzoska
- Department of Epidemiology & International Public Health, School of Public Health, University of Bielefeld, Germany
| | - Ugo Fedeli
- SER-Epidemiological Department, Veneto Region, Castelfranco (TV), Italy
| | - Claudia Larouche
- Department of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland and Labrador, Canada
| | - Oliver Razum
- Department of Epidemiology & International Public Health, School of Public Health, University of Bielefeld, Germany
| | - Isaac C-H Fung
- Department of Infectious Disease Epidemiology, St. Mary's Campus, Imperial College London, UK
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Disertori M, Latini R, Maggioni AP, Delise P, Di Pasquale G, Franzosi MG, Staszewsky L, Tognoni G. Rationale and design of the GISSI-Atrial Fibrillation Trial: a randomized, prospective, multicentre study on the use of valsartan, an angiotensin II AT1-receptor blocker, in the prevention of atrial fibrillation recurrence. J Cardiovasc Med (Hagerstown) 2006; 7:29-38. [PMID: 16645357 DOI: 10.2459/01.jcm.0000199778.85343.08] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The possibility of preventing atrial fibrillation recurrence with anti-arrhythmic agents is very limited, given the discouraging results obtained with current drugs in many patients. Data from experimental studies suggest that angiotensin II AT1-receptor blockers can influence atrial remodelling, a key factor in atrial fibrillation initiation and maintenance. Moreover, some preliminary clinical data show that angiotensin II AT1 -receptor blockers can prevent atrial fibrillation episodes. The GISSI-Atrial Fibrillation (AF) trial is a randomized, prospective, parallel group, placebo-controlled, multicentre study designed to test whether angiotensin II AT1-receptor blockers can reduce atrial fibrillation recurrence. OBJECTIVES AND METHODS The primary objective of the study is to demonstrate that, in patients with a history of recent atrial fibrillation who are treated with the best recommended therapies, the addition of the angiotensin II AT1-receptor blocker valsartan (titrated up to 320 mg) is superior to placebo in reducing atrial fibrillation recurrence. A substudy will analyse the effect of valsartan on left atrial dimensions and on neurohormones. The study population consists of patients with symptomatic atrial fibrillation (at least two electrocardiogram documented atrial fibrillation episodes in the previous 6 months or successful cardioversion in the last 2 weeks) with underlying cardiovascular diseases or comorbidities. With approximately 100 centres participating in Italy, a total of 1402 patients are randomized in a 1 : 1 ratio to receive valsartan or placebo. The enrolment period will last 12 months and the patients will be followed for 12 months from study entry. CONCLUSIONS The GISSI-AF is the largest trial aimed at assessing the role of angiotensin receptor blockade in reducing the recurrence of atrial fibrillation and its possible mechanisms of action in terms of its effects on atrium remodelling and neurohormones.
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Macchia A, Levantesi G, Marfisi RM, Franzosi MG, Maggioni AP, Nicolosi GL, Schweiger C, Tavazzi L, Tognoni G, Valagussa F, Marchioli R. Determinantes de insuficiencia cardíaca tardía postinfarto de miocardio: resultados del estudio GISSI Prevenzione. Rev Esp Cardiol 2005. [DOI: 10.1157/13080953] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Marchioli R, Finazzi G, Marfisi RM, Tognoni G, Barbui T. Clinical Trials in Myeloproliferative Disorders: Looking Forward. Semin Hematol 2005; 42:259-65. [PMID: 16210039 DOI: 10.1053/j.seminhematol.2005.05.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although far from perfect, randomized clinical trials (RCTs) are the best mechanism available for evaluating the risk/benefit profile of a particular therapy. Given this, it is particularly unfortunate that there have been few clinical trials of therapy for myeloproliferative diseases (MPDs) as these therapies are often based on agents with unclear long-term safety. A complex profile of MPD uncertainties requires a simple, but articulated strategy of care and research to allow a reasonable transfer of the best available validated knowledge and a timely investigation of the most relevant questions. The multi-country, collaborative RCTs are key to generating valid data. The prerequisite for success is the close interaction of the clinical community and the research community studying the same patients. Data to be collected, criteria, contents, frequency of follow-up, and documentation of the events should be as similar as possible to those used in routine clinical care. One of the greatest achievements of the multicenter trials with this orientation has been to produce a "core" of data and practices, on which the main analyses will be made, but which at the same time reflect an optimal level of patient care for the majority of patients.
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Affiliation(s)
- Roberto Marchioli
- Laboratory of Epidemiology of Cardiovascular Disease, Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, Via Nazionale 8, 66030 Santa Maria Imbaro, Chieti, Italy.
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Yusuf S. Transforming the scientific, health care, and sociopolitical culture of an entire country through clinical research: the story of GISSI. Am Heart J 2004; 148:193-5. [PMID: 15308987 DOI: 10.1016/j.ahj.2004.03.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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