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Malecki S, Loffler A, Liao F, Hora T, Agarwal A, Lail S, Roberts SB, McFadden D, Gupta S, Razak F, Verma AA. Real-world use of glucocorticoids and clinical outcomes in adults hospitalized with community-acquired pneumonia on medical wards. J Hosp Med 2024. [PMID: 38824463 DOI: 10.1002/jhm.13422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Little is known about the real-world use of systemic glucocorticoids to treat patients hospitalized with community-acquired pneumonia (CAP) outside of the intensive care unit (ICU). METHODS This retrospective cohort study included 11,588 hospitalizations for CAP without chronic pulmonary disease at seven hospitals in Ontario, Canada. We report physician-level variation in the use of glucocorticoids and trends over time. We investigated the association between glucocorticoid prescriptions and clinical outcomes, using propensity score overlap weighting to account for confounding by indication. RESULTS Glucocorticoids were prescribed in 1283 (11.1%) patients, increasing over time from 10.0% in 2010 to 11.9% in 2020 (p = .008). Physician glucocorticoid prescribing ranged from 2.9% to 34.6% (median 10.0%, inter quartile range [IQR]: 6.7%-14.6%). Patients receiving glucocorticoids tended to be younger (median age 73 vs. 79), have higher Charlson comorbidity scores (score of 2 or more: 42.4% vs. 31.0%), more cancer (26.6% vs. 13.2%), more renal disease (11.5% vs. 6.6%), and less dementia (7.8% vs. 14.8%). Patients treated with glucocorticoids had higher rates of in-hospital mortality (weighted Risk Difference = 1.72, 95% confidence interval [95% CI]: 0.16-3.3, p = .033). Glucocorticoid use was not associated with ICU admission, hospital length-of-stay, or 30-day readmission. CONCLUSION Glucocorticoids were prescribed in 11.1% of patients hospitalized with CAP outside of ICU and one in four physicians prescribed glucocorticoids in more than 14% of patients. Glucocorticoid use was associated with greater in-hospital mortality, although these findings are limited by large selection effects. Clinicians should exercise caution in prescribing glucocorticoids for nonsevere CAP, and definitive trials are needed in this population.
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Affiliation(s)
- Sarah Malecki
- Internal Medicine Residency Program, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Anne Loffler
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Fangming Liao
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Tejasvi Hora
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Arnav Agarwal
- Internal Medicine Residency Program, University of Toronto, Toronto, Ontario, Canada
| | - Sharan Lail
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Surain B Roberts
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Derek McFadden
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Samir Gupta
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Fahad Razak
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Amol A Verma
- Internal Medicine Residency Program, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
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2
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Liu J, Dong Y, Chen J, Jin Y, Qiu Y, Huang L. Corticosteroid in non-COVID-19 induced community-acquired pneumonia, a meta-analysis. Heart Lung 2024; 65:59-71. [PMID: 38432039 DOI: 10.1016/j.hrtlng.2024.02.004] [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: 12/06/2023] [Revised: 02/07/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Corticosteroid treatment in non-COVID-19 induced Community-acquired pneumonia (CAP) remains inconclusive. OBJECTIVES We aimed to assess the role of corticosteroid treatment in CAP. METHODS We conducted a comprehensive search of online databases, including PubMed, Embase, and Cochrane, to identify articles published from January 1, 2000, to May 5, 2023. Double-blind RCTs were selected. Two authors screened studies and extracted data. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS We analyzed data from 12 RCTs, involving 2446 patients. Corticosteroids therapy may reduce short-term mortality in patients with severe CAP (sCAP) and shorten the hospital length of stay in patients with CAP. Furthermore, corticosteroids treatment can decrease the risk of requiring mechanical ventilation, developing septic shock and multiple organ dysfunction syndrome (MODS). There were no significant differences between the corticosteroid and control groups concerning gastrointestinal bleeding and nosocomial infection. The use of corticosteroids could increase the risk of hyperglycemia. CONCLUSION Corticosteroid treatment for sCAP has the potential to provide benefits in reducing short-term mortality, but this conclusion necessitates more evidence. Besides, we found no evidence that strongly prevents us from using corticosteroids in patients with sCAP or those at risk of progressing to sCAP.
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Affiliation(s)
- Jian Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Yongquan Dong
- Department of Respiratory Disease, YinZhou Second Hospital, Ningbo, Zhejiang, China
| | - Jia Chen
- Research Center for Healthcare Data Science, Zhejiang Lab, Hangzhou, Zhejiang, China
| | - Yuqing Jin
- Research Center for Healthcare Data Science, Zhejiang Lab, Hangzhou, Zhejiang, China
| | - Yunqing Qiu
- Zhejiang Provincial Key Laboratory for Drug Clinical Research and Evaluation, Department of Clinical Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Lingtong Huang
- Department of Critical Care Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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3
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Waterer GW, Metersky M. Corticosteroids and Severe Community-acquired Pneumonia: New Data, New Questions and a Swinging Pendulum. Arch Bronconeumol 2023; 59:793-794. [PMID: 37625907 DOI: 10.1016/j.arbres.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Grant W Waterer
- East Metropolitan Health Service, Royal Perth Hospital, Perth, Australia.
| | - Mark Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, Connecticut, United States
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4
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Kanjee Z, Metlay JP, Moskowitz A, Reynolds EE. How Would You Treat This Patient Hospitalized With Community-Acquired Pneumonia? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2021; 174:1719-1726. [PMID: 34904883 DOI: 10.7326/m21-3650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Community-acquired pneumonia is a major cause of morbidity and mortality in the United States, leading to 1.5 million hospitalizations and at least 200 000 deaths annually. The 2019 American Thoracic Society/Infectious Diseases Society of America clinical practice guideline on diagnosis and treatment of adults with community-acquired pneumonia provides an evidence-based overview of this common illness. Here, 2 experts, a general internist who served as the co-primary author of the guidelines and a pulmonary and critical care physician, debate the management of a patient hospitalized with community-acquired pneumonia. They discuss disease severity stratification methods, whether to use adjunctive corticosteroids, and when to prescribe empirical treatment for multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa.
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Affiliation(s)
- Zahir Kanjee
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., E.E.R.)
| | - Joshua P Metlay
- Massachusetts General Hospital, Boston, Massachusetts (J.P.M.)
| | | | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., E.E.R.)
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5
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Wang M, Gauthier AG, Kennedy TP, Wang H, Velagapudi UK, Talele TT, Lin M, Wu J, Daley L, Yang X, Patel V, Mun SS, Ashby CR, Mantell LL. 2-O, 3-O desulfated heparin (ODSH) increases bacterial clearance and attenuates lung injury in cystic fibrosis by restoring HMGB1-compromised macrophage function. Mol Med 2021; 27:79. [PMID: 34271850 PMCID: PMC8283750 DOI: 10.1186/s10020-021-00334-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 06/21/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND High mobility group box 1 protein (HMGB1) is an alarmin following its release by immune cells upon cellular activation or stress. High levels of extracellular HMGB1 play a critical role in impairing the clearance of invading pulmonary pathogens and dying neutrophils in the injured lungs of cystic fibrosis (CF) and acute respiratory distress syndrome (ARDS). A heparin derivative, 2-O, 3-O desulfated heparin (ODSH), has been shown to inhibit HMGB1 release from a macrophage cell line and is efficacious in increasing bacterial clearance in a mouse model of pneumonia. Thus, we hypothesized that ODSH can attenuate the bacterial burden and inflammatory lung injury in CF and we conducted experiments to determine the underlying mechanisms. METHODS We determined the effects of ODSH on lung injury produced by Pseudomonas aeruginosa (PA) infection in CF mice with the transmembrane conductance regulator gene knockout (CFTR-/-). Mice were given ODSH or normal saline intraperitoneally, followed by the determination of the bacterial load and lung injury in the airways and lung tissues. ODSH binding to HMGB1 was determined using surface plasmon resonance and in silico docking analysis of the interaction of the pentasaccharide form of ODSH with HMGB1. RESULTS CF mice given 25 mg/kg i.p. of ODSH had significantly lower PA-induced lung injury compared to mice given vehicle alone. The CF mice infected with PA had decreased levels of nitric oxide (NO), increased levels of airway HMGB1 and HMGB1-impaired macrophage phagocytic function. ODSH partially attenuated the PA-induced alteration in the levels of NO and airway HMGB1 in CF mice. In addition, ODSH reversed HMGB1-impaired macrophage phagocytic function. These effects of ODSH subsequently decreased the bacterial burden in the CF lungs. In a surface plasmon resonance assay, ODSH interacted with HMGB1 with high affinity (KD = 3.89 × 10-8 M) and induced conformational changes that may decrease HMGB1's binding to its membrane receptors, thus attenuating HMGB1-induced macrophage dysfunction. CONCLUSIONS The results suggest that ODSH can significantly decrease bacterial infection-induced lung injury in CF mice by decreasing both HMGB1-mediated impairment of macrophage function and the interaction of HMGB1 with membrane receptors. Thus, ODSH could represent a novel approach for treating CF and ARDS patients that have HMGB1-mediated lung injury.
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Affiliation(s)
- Mao Wang
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - Alex G Gauthier
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - Thomas P Kennedy
- Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Haichao Wang
- The Feinstein Institute for Medical Research, Northwell Health System, Manhasset, NY, USA
| | - Uday Kiran Velagapudi
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - Tanaji T Talele
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - Mosi Lin
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - Jiaqi Wu
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - LeeAnne Daley
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - Xiaojing Yang
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - Vivek Patel
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - Sung Soo Mun
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - Charles R Ashby
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA
| | - Lin L Mantell
- Department of Pharmaceutical Sciences, St. John's University College of Pharmacy and Health Sciences, Queens, 11439, NY, USA.
- The Feinstein Institute for Medical Research, Northwell Health System, Manhasset, NY, USA.
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6
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Waterer GW. Applying the lessons learned from coronavirus disease 2019 to improve pneumonia management. Curr Opin Infect Dis 2021; 34:175-179. [PMID: 33492003 DOI: 10.1097/qco.0000000000000710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Coronavirus disease 2019 (COVID-19) has produced an extraordinary amount of literature in a short time period. This review focuses on what the new literature has provided in terms of more general information about the management of community-acquired pneumonia (CAP). RECENT FINDINGS Measures taken to reduce the spread of COVID-19 have caused a significant drop in influenza worldwide. Improvements in imaging, especially ultrasound, and especially in the application of rapid molecular diagnosis are likely to have significant impact on the management of CAP. Therapeutic advances are so far limited. SUMMARY COVID-19 has taught us that we can do far more to prevent seasonal influenza and its associated mortality, morbidity and economic cost. Improvements in imaging and pathogen diagnosis are welcome, as is the potential for secondary benefits of anti-COVID-19 therapies that may have reach effect on respiratory viruses other than severe acute respiratory syndrome coronavirus 2. As community-transmission is likely to persist for many years, recognition and treatment of severe acute respiratory syndrome coronavirus 2 will need to be incorporated into CAP guidelines moving forward.
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Affiliation(s)
- Grant W Waterer
- Department of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Northwestern University, Chicago, Illinois, USA
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7
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Jones B, Waterer G. Advances in community-acquired pneumonia. Ther Adv Infect Dis 2020; 7:2049936120969607. [PMID: 33224494 PMCID: PMC7656869 DOI: 10.1177/2049936120969607] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/07/2020] [Indexed: 12/24/2022] Open
Abstract
Community-acquired pneumonia is one of the commonest and deadliest of the infectious diseases, yet our understanding of it remains relatively poor. The recently published American Thoracic Society and Infectious Diseases Society of America Community-acquired pneumonia guidelines acknowledged that most of what we accept as standard of care is supported only by low quality evidence, highlighting persistent uncertainty and deficiencies in our knowledge. However, progress in diagnostics, translational research, and epidemiology has changed our concept of pneumonia, contributing to a gradual improvement in prevention, diagnosis, treatment, and outcomes for our patients. The emergence of considerable evidence about adverse long-term health outcomes in pneumonia survivors has also challenged our concept of pneumonia as an acute disease and what treatment end points are important. This review focuses on advances in the research and care of community-acquired pneumonia in the past two decades. We summarize the evidence around our understanding of pathogenesis and diagnosis, discuss key contentious management issues including the role of procalcitonin and the use or non-use of corticosteroids, and explore the relationships between pneumonia and long-term outcomes including cardiovascular and cognitive health.
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Affiliation(s)
- Barbara Jones
- Division of Pulmonary and Critical Care, University of Utah and Salt Lake City VA Healthcare System, Salt Lake City, UT, USA
| | - Grant Waterer
- University of Western Australia, Royal Perth Hospital, Perth, WA 6009, Australia
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8
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Feldman C, Anderson R. Platelets and Their Role in the Pathogenesis of Cardiovascular Events in Patients With Community-Acquired Pneumonia. Front Immunol 2020; 11:577303. [PMID: 33042161 PMCID: PMC7527494 DOI: 10.3389/fimmu.2020.577303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/24/2020] [Indexed: 12/21/2022] Open
Abstract
Community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality throughout the world with much recent and ongoing research focused on the occurrence of cardiovascular events (CVEs) during the infection, which are associated with adverse short-term and long-term survival. Much of the research directed at unraveling the pathogenesis of these events has been undertaken in the settings of experimental and clinical CAP caused by the dangerous, bacterial respiratory pathogen, Streptococcus pneumoniae (pneumococcus), which remains the most common bacterial cause of CAP. Studies of this type have revealed that although platelets play an important role in host defense against infection, there is also increasing recognition that hyperactivation of these cells contributes to a pro-inflammatory, prothrombotic systemic milieu that contributes to the etiology of CVEs. In the case of the pneumococcus, platelet-driven myocardial damage and dysfunction is exacerbated by the direct cardiotoxic actions of pneumolysin, a major pore-forming toxin of this pathogen, which also acts as potent activator of platelets. This review is focused on the role of platelets in host defense against infection, including pneumococcal infection in particular, and reviews the current literature describing the potential mechanisms by which platelet activation contributes to cardiovascular complications in CAP. This is preceded by an evaluation of the burden of pneumococcal infection in CAP, the clinical features and putative pathogenic mechanisms of the CVE, and concludes with an evaluation of the potential utility of the anti-platelet activity of macrolides and various adjunctive therapies.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, Institute of Cellular and Molecular Medicine, University of Pretoria, Pretoria, South Africa
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9
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Rello J, Blanch L, Preiser JC, De Waele JJ. How to improve research on management of critically ill patients: Lessons learned from negative randomised clinical trials in the intensive care unit. Anaesth Crit Care Pain Med 2020; 39:173-174. [PMID: 32058127 PMCID: PMC8166406 DOI: 10.1016/j.accpm.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Jordi Rello
- Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain; Centre Hôpitalier Universitaire Nîmes, Université Montpellier-Nîmes, France.
| | - Lluis Blanch
- I3PT Institut d'Investigacio i Innovació Parc Tauli, Sabadell, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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10
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Use of glucocorticoids in the critical care setting: Science and clinical evidence. Pharmacol Ther 2020; 206:107428. [DOI: 10.1016/j.pharmthera.2019.107428] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
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11
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Abstract
Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality despite adequate antibiotic therapy. It is the single most common cause of infection-related mortality in the United States. An exaggerated host inflammatory response can potentially be harmful to both the lung and host, and has been associated with treatment failure and mortality. Modulation of inflammatory response may, therefore, be theoretically beneficial. The anti-inflammatory and immunosuppressive effects of steroids seem an attractive therapeutic option in severe CAP patients. Available datapoint to overall shorter time to clinical stability and decreased length-of-stay in CAP patients, with a potential mortality benefit in severe CAP. The level of evidence is, however, low to moderate regarding mortality due to high heterogeneity and insufficient power of data. Furthermore, steroids were deleterious in influenza pneumonia and in patients with pneumococcal pneumonia data suggest a lack of efficacy and potential harm. Both European and American guidelines recommend not using corticosteroids in CAP. Patients who might benefit and those that can be harmed from steroids remain to be clearly identified, as does the ideal steroid for CAP patients, based on pharmacokinetic and pharmacodynamic properties. It is essential for future studies to avoid the same methodological bias present in the available data so that high-quality evidence on the true role of steroids in CAP can be provided.
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Affiliation(s)
- David Nora
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Wagner Nedel
- Intensive Care Unit, Hospital Nossa Senhora Da Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Hospital De Clínicas De Porto Alegre, Post-Graduation Program (PPG) Pneumology,Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Jorge Salluh
- D'or Institute for Research and Education, Rio De Janeiro, Brazil
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
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