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Pessoa-Amorim G, Goldacre R, Crichton C, Stevens W, Nunn M, King A, Murray D, Welsh R, Pinches H, Rees A, Morris EJA, Landray MJ, Haynes R, Horby P, Wallendszus K, Peto L, Campbell M, Harper C, Mafham M. Clinical trial results in context: comparison of baseline characteristics and outcomes of 38,510 RECOVERY trial participants versus a reference population of 346,271 people hospitalised with COVID-19 in England. Trials 2024; 25:429. [PMID: 38951929 PMCID: PMC11218071 DOI: 10.1186/s13063-024-08273-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/19/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Randomised trials are essential to reliably assess medical interventions. Nevertheless, interpretation of such studies, particularly when considering absolute effects, is enhanced by understanding how the trial population may differ from the populations it aims to represent. METHODS We compared baseline characteristics and mortality of RECOVERY participants recruited in England (n = 38,510) with a reference population hospitalised with COVID-19 in England (n = 346,271) from March 2020 to November 2021. We used linked hospitalisation and mortality data for both cohorts to extract demographics, comorbidity/frailty scores, and crude and age- and sex-adjusted 28-day all-cause mortality. RESULTS Demographics of RECOVERY participants were broadly similar to the reference population, but RECOVERY participants were younger (mean age [standard deviation]: RECOVERY 62.6 [15.3] vs reference 65.7 [18.5] years) and less frequently female (37% vs 45%). Comorbidity and frailty scores were lower in RECOVERY, but differences were attenuated after age stratification. Age- and sex-adjusted 28-day mortality declined over time but was similar between cohorts across the study period (RECOVERY 23.7% [95% confidence interval: 23.3-24.1%]; vs reference 24.8% [24.6-25.0%]), except during the first pandemic wave in the UK (March-May 2020) when adjusted mortality was lower in RECOVERY. CONCLUSIONS Adjusted 28-day mortality in RECOVERY was similar to a nationwide reference population of patients admitted with COVID-19 in England during the same period but varied substantially over time in both cohorts. Therefore, the absolute effect estimates from RECOVERY were broadly applicable to the target population at the time but should be interpreted in the light of current mortality estimates. TRIAL REGISTRATION ISRCTN50189673- Feb. 04, 2020, NCT04381936- May 11, 2020.
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Affiliation(s)
- Guilherme Pessoa-Amorim
- Clinical Trial Service Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX37LF, UK.
- Medical Research Council Population Health Research Unit, Oxford Population Health, University of Oxford, Oxford, UK.
| | - Raphael Goldacre
- Big Data Institute, Oxford Population Health, University of Oxford, Oxford, UK
| | - Charles Crichton
- Big Data Institute, Oxford Population Health, University of Oxford, Oxford, UK
| | - Will Stevens
- Clinical Trial Service Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX37LF, UK
- Medical Research Council Population Health Research Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Michelle Nunn
- Clinical Trial Service Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX37LF, UK
- Medical Research Council Population Health Research Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Andy King
- National Perinatal Epidemiology Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Dave Murray
- National Perinatal Epidemiology Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Richard Welsh
- National Perinatal Epidemiology Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | | | | | - Eva J A Morris
- Big Data Institute, Oxford Population Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Martin J Landray
- Clinical Trial Service Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX37LF, UK
- Medical Research Council Population Health Research Unit, Oxford Population Health, University of Oxford, Oxford, UK
- Big Data Institute, Oxford Population Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Haynes
- Clinical Trial Service Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX37LF, UK
- Medical Research Council Population Health Research Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Peter Horby
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- International Severe Acute Respiratory and emerging Infections Consortium (ISARIC), University of Oxford, Oxford, UK
- Pandemic Sciences Centre, University of Oxford, Oxford, UK
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karl Wallendszus
- Clinical Trial Service Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX37LF, UK
- Medical Research Council Population Health Research Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Leon Peto
- Clinical Trial Service Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX37LF, UK
- Medical Research Council Population Health Research Unit, Oxford Population Health, University of Oxford, Oxford, UK
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mark Campbell
- Clinical Trial Service Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX37LF, UK
- Medical Research Council Population Health Research Unit, Oxford Population Health, University of Oxford, Oxford, UK
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Charlie Harper
- Clinical Trial Service Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX37LF, UK
- Medical Research Council Population Health Research Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Marion Mafham
- Clinical Trial Service Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX37LF, UK
- Medical Research Council Population Health Research Unit, Oxford Population Health, University of Oxford, Oxford, UK
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Li G, Zhong S, Wang X, Zhuge F. Association of hypoglycaemia with the risks of arrhythmia and mortality in individuals with diabetes - a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1222409. [PMID: 37645418 PMCID: PMC10461564 DOI: 10.3389/fendo.2023.1222409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
Background Hypoglycaemia has been linked to an increased risk of cardiac arrhythmias by causing autonomic and metabolic alterations, which may be associated with detrimental outcomes in individuals with diabetes(IWD), such as cardiovascular diseases (CVDs) and mortality, especially in multimorbid or frail people. However, such relationships in this population have not been thoroughly investigated. For this reason, we conducted a systematic review and meta-analysis. Methods Relevant papers published on PubMed, Embase, Cochrane, Web of Knowledge, Scopus, and CINHAL complete from inception to December 22, 2022 were routinely searched without regard for language. All of the selected articles included odds ratio, hazard ratio, or relative risk statistics, as well as data for estimating the connection of hypoglycaemia with cardiac arrhythmia, CVD-induced death, or total death in IWD. Regardless of the heterogeneity assessed by the I2 statistic, pooled relative risks (RRs) and 95% confidence intervals (CI) were obtained using random-effects models. Results After deleting duplicates and closely evaluating all screened citations, we chose 60 studies with totally 5,960,224 participants for this analysis. Fourteen studies were included in the arrhythmia risk analysis, and 50 in the analysis of all-cause mortality. Hypoglycaemic patients had significantly higher risks of arrhythmia occurrence (RR 1.42, 95%CI 1.21-1.68), CVD-induced death (RR 1.59, 95% CI 1.24-2.04), and all-cause mortality (RR 1.68, 95% CI 1.49-1.90) compared to euglycaemic patients with significant heterogeneity. Conclusion Hypoglycaemic individuals are more susceptible to develop cardiac arrhythmias and die, but evidence of potential causal linkages beyond statistical associations must await proof by additional specifically well planned research that controls for all potential remaining confounding factors.
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Affiliation(s)
- Gangfeng Li
- Clinical Laboratory Center, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Shuping Zhong
- Department of Hospital Management, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Xingmu Wang
- Clinical Laboratory Center, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Fuyuan Zhuge
- Department of Endocrine and Metabolism, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
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Liu W, Wang CC, Lee KH, Ma X, Kang TL. Research methodology in acupuncture and moxibustion for managing primary dysmenorrhea: A scoping review. Complement Ther Med 2022; 71:102874. [PMID: 35998757 DOI: 10.1016/j.ctim.2022.102874] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 07/20/2022] [Accepted: 08/19/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acupuncture and moxibustion have promising effects in managing primary dysmenorrhea. However, some evidence from clinical trials remains controversial due to methodological flaws in study designs that involve acupuncture and its related modalities and require urgent attention and dialogue. METHODS Allied and Complementary Medicine Database (AMED), Cochrane Library, Excerpta Medica database (EMBASE), PubMed, Web of Sciences, Chinese Biological Medicine (CBM), China National Knowledge Infrastructure (CNKI), VIP Database for Chinese Technical Periodicals (VIP), and Wanfang database were searched from their inception to July 2021. Data were extracted based on the types of study design, primary outcome measures, adverse events (AEs), and participants' subjective views. RESULTS Most studies (n = 282, 93 %) were published in Chinese and 21 (7 %) in English. Among these, there were 209 (69 %) randomized controlled trials (RCTs), 39 (13 %) non-randomized controlled trials (nRCTs), 30 (10 %) case-series reports, 15 (5 %) cohort studies, and 10 (3 %) case reports. The most frequent reported outcome was pain, followed by emotion, sleeping quality, quality of life, skin temperature, changes in brain function, uterine and ovarian blood flow, and reproductive endocrine level. AEs were reported in 37 studies with mild events, and all recovered without actions taken; 31 trials reported no AEs; 235 failed to report any AEs. One RCT found that the satisfaction rate of the intervention group was statistically significantly higher than the control group. CONCLUSION Clinical studies on acupuncture and its related modalities face methodological challenges and require urgent attention. RCT with blinding and sham control might be the gold standard trial design. However, it may not be the most suitable research method for these modalities. We recommend using pragmatic RCTs in this field, where trial protocol registration on the trial registry platforms and detailed safety reporting should be mandatory.
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Affiliation(s)
- Weiting Liu
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia.
| | - Carol Chunfeng Wang
- School of Nursing, Midwifery, Health Sciences & Physiotherapy, The University of Notre Dame Australia, Perth, Australia
| | - Khui Hung Lee
- School of Science, Edith Cowan University, Perth, Australia
| | - Xiaopeng Ma
- Shanghai Research Institute of Acupuncture and Meridian, Shanghai, China
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Bath PM, Mhlanga I, Woodhouse LJ, Doubal F, Oatey K, Montgomery AA, Wardlaw JM. Cilostazol and isosorbide mononitrate for the prevention of progression of cerebral small vessel disease: baseline data and statistical analysis plan for the Lacunar Intervention Trial-2 (LACI-2) (ISRCTN14911850). Stroke Vasc Neurol 2022; 8:134-143. [PMID: 36219567 PMCID: PMC10176977 DOI: 10.1136/svn-2022-001816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/16/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Cerebral small vessel disease (SVD) causes lacunar strokes (25% of all ischaemic strokes), physical frailty and cognitive impairment and vascular and mixed dementia. There is no specific treatment to prevent progression of SVD. METHODS The LACunar Intervention Trial-2 is an investigator-initiated prospective randomised open-label blinded-endpoint phase II feasibility study assessing cilostazol and isosorbide mononitrate for preventing SVD progression. We aimed to recruit 400 patients with clinically evident lacunar ischaemic stroke and randomised to cilostazol, isosorbide mononitrate, both or neither, in addition to guideline secondary ischaemic stroke prevention, in a partial factorial design. The primary outcome is feasibility of recruitment and adherence to medication; key secondary outcomes include: drug tolerability; recurrent vascular events, cognition and function at 1 year after randomisation; and safety (bleeding, falls, death). Data are number (%) and median (IQR). RESULTS The trial commenced on 5 February 2018 and ceased recruitment on 31 May 2021 with 363 patients randomised, with the following baseline characteristics: average age 64 (56.0, 72.0) years, female 112 (30.9%), stroke onset to randomisation 79.0 (27.0, 244.0) days, hypertension 267 (73.6%), median blood pressures 143.0 (130.0, 157.0)/83.0 (75.0, 90.0) mm Hg, current smokers 67 (18.5%), educationally achieved end of school examinations (A-level) or higher 118 (32.5%), modified Rankin scale 1.0 (0.0, 1.0), National Institutes Health stroke scale 1.0 (1.4), Montreal Cognitive Assessment 26.0 (23.0, 28.0) and total SVD score on brain imaging 1.0 (0.0, 2.0). This publication summarises the baseline data and presents the statistical analysis plan. SUMMARY The trial is currently in follow-up which will complete on 31 May 2022 with results expected in October 2022. TRIAL REGISTRATION NUMBER ISRCTN14911850.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Iris Mhlanga
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Fergus Doubal
- Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre, University of Edinburgh, Edinburgh, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre, University of Edinburgh, Edinburgh, UK
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Eccleston D, Scalia G, Kearney L, Cross D, Cehic D, Disney P, Xu XF, Cain P, Srivastava PM. Genesis of improved quality in imaging through a national Australian echocardiography registry. Open Heart 2022; 9:openhrt-2021-001797. [PMID: 35534092 PMCID: PMC9086615 DOI: 10.1136/openhrt-2021-001797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/06/2022] [Indexed: 11/09/2022] Open
Abstract
Background Despite rapid technological advances and growth, quality in imaging has not received the focus seen elsewhere in cardiovascular medicine, resulting in significant gaps between guidelines and practice. Contemporary echocardiography practice requires comprehensive real-time data collection to allow dynamic auditing and benchmarking of key performance indices. The American College of Cardiology (ACC) proposed additional data standardisation, structured reporting identifying key data elements and imaging registries. In the absence of an Australian echocardiography registry, we developed a national clinical quality registry (GenesisCare Cardiovascular Outcomes Echo Registry). We hypothesised that measurement and local reporting of data would improve compliance of echo studies with quality guidelines and hence their clinical value. Methods and results We prospectively collected data on 4 099 281 echocardiographic studies entered directly into a central electronic database from 63 laboratories across four Australian states between 2010 and 2021. Real-time auditing of key data elements and introduction of quality improvement pathways were performed to maximise completeness and uniformity of data acquisition and reporting. We compared completeness of key data element acquisition (AV peak velocity, left ventricular ejection fraction, E/e’, LA area, rhythm, RVSP) by time and state using de-identified data. Key performance outcomes benchmarked against the aggregated study cohort and international standards were reported to individual sites to drive quality improvement. Between 2010 and 2014 there were significant improvements in data completeness (72.0%+/-26.8% vs 86.8%+/-13.5%, p=0.02), which were maintained to 2020. In addition, interstate variability fell for both EF and E/e’ (p<0.002). Conclusions This large-scale collaboration provides a platform for the development of major quality improvement initiatives in echocardiography. Introduction of local quality assurance programmes via a unified national data set significantly improved the completeness of reporting of key echo quality measures. This in turn significantly improved the quality of, and reduced the interstate variability of, echo data. Developing a centralised database allowed rapid adoption nationally of local quality improvements.
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Affiliation(s)
- David Eccleston
- Medicine, University of Melbourne School of BioSciences, Melbourne, Victoria, Australia .,Cardiology, GenesisCare, Alexandria, New South Wales, Australia
| | - Gregory Scalia
- Cardiology, GenesisCare, Alexandria, New South Wales, Australia.,Cardiology, Wesley Hospital, Brisbane, Queensland, Australia
| | - Leighton Kearney
- Cardiology, GenesisCare, Alexandria, New South Wales, Australia.,Cardiology, Warringal Private Hospital, Heidelberg, Victoria, Australia
| | - David Cross
- Cardiology, GenesisCare, Alexandria, New South Wales, Australia.,Cardiology, Wesley Hospital, Brisbane, Queensland, Australia
| | - Daniel Cehic
- Cardiology, GenesisCare, Alexandria, New South Wales, Australia.,Cardiology, St Andrew's Hospital, Adelaide, South Australia, Australia
| | - Patrick Disney
- Cardiology, GenesisCare, Alexandria, New South Wales, Australia.,Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Xiao-Fang Xu
- Cardiology, GenesisCare, Alexandria, New South Wales, Australia.,Cardiology, St John of God Hospital Murdoch, Murdoch, Western Australia, Australia
| | - Peter Cain
- Cardiology, GenesisCare, Alexandria, New South Wales, Australia.,Cardiology, Wesley Hospital, Brisbane, Queensland, Australia
| | - Piyush M Srivastava
- Medicine, University of Melbourne School of BioSciences, Melbourne, Victoria, Australia.,Cardiology, GenesisCare, Alexandria, New South Wales, Australia
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Sorokoumov VA. Anticoagulant therapy for the prevention of recurrent stroke in patients with atrial fibrillation: a comprehensive risk management. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Effective secondary prevention of ischemic stroke in patients with atrial fibrillation (AF) implies long-term oral anticoagulant therapy. It has been proven that the use of direct oral anticoagulants (DOACs) is more effective, safer and more convenient for a patient than vitamin K antagonists. However, the selection of most effective and safe DOAC represented without direct comparisons in randomized controlled trials (RCTs) cannot be reliable due to the inevitable differences in the cohorts of studied patients and differences in methodological approaches. It should be noted that the population of patients in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) in terms of basic characteristics was as close as possible to the Russian population of AF patients compared with study populations of other DOACs. Of great importance for ensuring the overall benefit from DOACs is the possibility of comprehensive protection of the elderly patient with AF. This approach, along with the risk of recurrent stroke and possible bleeding events, takes into account other risks that can significantly worsen the prognosis and health of a patient with AF, such as the risk of coronary events, impairment of renal function, and cognitive impairment that can lead to low adherence to treatment. Rivaroxaban therapy makes it possible to simultaneously reduce the listed risks, providing comprehensive protection for an elderly patient with AF.
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Clinical Research: From Case Reports to International Multicenter Clinical Trials. Crit Care Med 2021; 49:1866-1882. [PMID: 34387238 DOI: 10.1097/ccm.0000000000005247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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8
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Albert RK. Informing Healthcare Decisions with Observational Research Assessing Causal Effect: An American Thoracic Society Statement Not Ready for Implementation. Am J Respir Crit Care Med 2021; 204:374-376. [PMID: 34081880 PMCID: PMC8513590 DOI: 10.1164/rccm.202102-0492le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Hankey GJ. Evolution of Evidence-Based Medicine in Stroke. Cerebrovasc Dis 2021; 50:644-655. [PMID: 34315156 DOI: 10.1159/000517679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022] Open
Abstract
The introduction and evolution of evidence-based stroke medicine has realized major advances in our knowledge about stroke, methods of medical research, and patient outcomes that continue to complement traditional individual patient care. It is humbling to recall the state of knowledge and scientific endeavour of our forebears who were unaware of what we know now and yet pursued the highest standards for evaluating and delivering effective stroke care. The science of stroke medicine has evolved from pathophysiological theory to empirical testing. Progress has been steady, despite inevitable disappointments and cul-de-sacs, and has occasionally been punctuated by sensational breakthroughs, such as the advent of reperfusion therapies guided by imaging.
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Affiliation(s)
- Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Washington, Australia.,Department of Neurology, Sir Charles Gairdner Hospital, Perth, Washington, Australia
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Pessoa-Amorim G, Campbell M, Fletcher L, Horby P, Landray M, Mafham M, Haynes R. Making trials part of good clinical care: lessons from the RECOVERY trial. Future Healthc J 2021; 8:e243-e250. [PMID: 34286192 PMCID: PMC8285150 DOI: 10.7861/fhj.2021-0083] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
When COVID-19 hit the UK in early 2020, there were no known treatments for a condition that results in the death of around one in four patients hospitalised with this disease. Around the world, possible treatments were administered to huge numbers of patients, without any reliable assessments of safety and efficacy. The rapid generation of high-quality evidence was vital. RECOVERY is a streamlined, pragmatic, randomised controlled trial, which was set up in response to this challenge. As of April 2021, over 39,000 patients have been enrolled from 178 hospital sites in the UK. Within 100 days of its initiation, RECOVERY demonstrated that dexamethasone improves survival for patients with severe disease; a result that was rapidly implemented in the UK and internationally saving hundreds of thousands of lives. Importantly, it also showed that other widely used treatments (such as hydroxychloroquine and azithromycin) have no meaningful benefit for hospitalised patients. This was only possible through randomisation of large numbers of patients and the adoption of streamlined and pragmatic procedures focused on quality, together with widespread collaboration focused on a single goal. RECOVERY illustrates how clinical trials and healthcare can be integrated, even in a pandemic. This approach provides new opportunities to generate the evidence needed for high-quality healthcare not only for a pandemic but for the many other conditions that place a burden on patients and the healthcare system.
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Affiliation(s)
- Guilherme Pessoa-Amorim
- Nuffield Department of Population Health, Oxford, UK and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- joint first authors
| | - Mark Campbell
- Nuffield Department of Population Health, Oxford, UK and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- joint first authors
| | - Lucy Fletcher
- Nuffield Department of Population Health, Oxford, UK
| | - Peter Horby
- Centre for Tropical Medicine and Global Health, Oxford, UK
| | - Martin Landray
- Nuffield Department of Population Health, Oxford, UK, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, NIHR Oxford Biomedical Research Centre, Oxford, UK and Health Data Research UK, Oxford, UK
| | - Marion Mafham
- Nuffield Department of Population Health, Oxford, UK, Oxford University Hospitals NHS Foundation Trust, Oxford, UK and Health Data Research UK, Oxford, UK
| | - Richard Haynes
- Nuffield Department of Population Health, Oxford, UK, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Cadarette SM, Maclure M, Delaney JAC, Whitaker HJ, Hayes KN, Wang SV, Tadrous M, Gagne JJ, Consiglio GP, Hallas J. Control yourself: ISPE-endorsed guidance in the application of self-controlled study designs in pharmacoepidemiology. Pharmacoepidemiol Drug Saf 2021; 30:671-684. [PMID: 33715267 PMCID: PMC8251635 DOI: 10.1002/pds.5227] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/15/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE Consensus is needed on conceptual foundations, terminology and relationships among the various self-controlled "trigger" study designs that control for time-invariant confounding factors and target the association between transient exposures (potential triggers) and abrupt outcomes. The International Society for Pharmacoepidemiology (ISPE) funded a working group of ISPE members to develop guidance material for the application and reporting of self-controlled study designs, similar to Standards of Reporting Observational Epidemiology (STROBE). This first paper focuses on navigation between the types of self-controlled designs to permit a foundational understanding with guiding principles. METHODS We leveraged a systematic review of applications of these designs, that we term Self-controlled Crossover Observational PharmacoEpidemiologic (SCOPE) studies. Starting from first principles and using case examples, we reviewed outcome-anchored (case-crossover [CCO], case-time control [CTC], case-case-time control [CCTC]) and exposure-anchored (self-controlled case-series [SCCS]) study designs. RESULTS Key methodological features related to exposure, outcome and time-related concerns were clarified, and a common language and worksheet to facilitate the design of SCOPE studies is introduced. CONCLUSIONS Consensus on conceptual foundations, terminology and relationships among SCOPE designs will facilitate understanding and critical appraisal of published studies, as well as help in the design, analysis and review of new SCOPE studies. This manuscript is endorsed by ISPE.
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Affiliation(s)
- Suzanne M Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA.,WHO Collaborating Centre for Governance, Accountability and Transparency in the Pharmaceutical Sector, Toronto, Ontario, Canada
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - J A Chris Delaney
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Heather J Whitaker
- Department of Mathematic and Statistics, The Open University, Milton Keynes, UK.,Department of Statistics, Modelling and Economics, Public Health England, London, UK
| | - Kaleen N Hayes
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Shirley V Wang
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital, Toronto, Ontario, Canada
| | - Joshua J Gagne
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Giulia P Consiglio
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, IST, University of Southern Denmark, Odense, Denmark.,Department of Clinical Pharmacology and Biochemistry, Odense University Hospital, Odense, Denmark
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Abstract
BACKGROUND This is the first update of this review first published in 2009. When treating elevated blood pressure, doctors usually try to achieve a blood pressure target. That target is the blood pressure value below which the optimal clinical benefit is supposedly obtained. "The lower the better" approach that guided the treatment of elevated blood pressure for many years was challenged during the last decade due to lack of evidence from randomised trials supporting that strategy. For that reason, the standard blood pressure target in clinical practice during the last years has been less than 140/90 mm Hg for the general population of patients with elevated blood pressure. However, new trials published in recent years have reintroduced the idea of trying to achieve lower blood pressure targets. Therefore, it is important to know whether the benefits outweigh harms when attempting to achieve targets lower than the standard target. OBJECTIVES The primary objective was to determine if lower blood pressure targets (any target less than or equal to 135/85 mm Hg) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (less than or equal to 140/ 90 mm Hg) for the treatment of patients with chronic arterial hypertension. The secondary objectives were: to determine if there is a change in mean achieved systolic blood pressure (SBP) and diastolic blood pressure (DBP associated with "lower targets" as compared with "standard targets" in patients with chronic arterial hypertension; and to determine if there is a change in withdrawals due to adverse events with "lower targets" as compared with "standard targets", in patients with elevated blood pressure. SEARCH METHODS The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to May 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 4), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing patients allocated to lower or to standard blood pressure targets (see above). DATA COLLECTION AND ANALYSIS Two review authors (JAA, VL) independently assessed the included trials and extracted data. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure, end stage renal disease, and other serious adverse events. Secondary outcomes were achieved mean SBP and DBP, withdrawals due to adverse effects, and mean number of antihypertensive drugs used. We assessed the risk of bias of each trial using the Cochrane risk of bias tool and the certainty of the evidence using the GRADE approach. MAIN RESULTS: This update includes 11 RCTs involving 38,688 participants with a mean follow-up of 3.7 years. This represents 7 new RCTs compared with the original version. At baseline the mean weighted age was 63.1 years and the mean weighted blood pressure was 155/91 mm Hg. Lower targets do not reduce total mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.86 to 1.05; 11 trials, 38,688 participants; high-certainty evidence) and do not reduce total serious adverse events (RR 1.04, 95% CI 0.99 to 1.08; 6 trials, 18,165 participants; moderate-certainty evidence). This means that the benefits of lower targets do not outweigh the harms as compared to standard blood pressure targets. Lower targets may reduce myocardial infarction (RR 0.84, 95% CI 0.73 to 0.96; 6 trials, 18,938 participants, absolute risk reduction (ARR) 0.4%, number needed to treat to benefit (NNTB) 250 over 3.7 years) and congestive heart failure (RR 0.75, 95% CI 0.60 to 0.92; 5 trials, 15,859 participants, ARR 0.6%, NNTB 167 over 3.7 years) (low-certainty for both outcomes). Reduction in myocardial infarction and congestive heart failure was not reflected in total serious adverse events. This may be due to an increase in other serious adverse events (RR 1.44, 95% CI 1.32 to 1.59; 6 trials. 18,938 participants, absolute risk increase (ARI) 3%, number needed to treat to harm (NNTH) 33 over four years) (low-certainty evidence). Participants assigned to a "lower" target received one additional antihypertensive medication and achieved a significantly lower mean SBP (122.8 mm Hg versus 135.0 mm Hg, and a lower mean DBP (82.0 mm Hg versus 85.2 mm Hg, than those assigned to "standard target". AUTHORS' CONCLUSIONS For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets. The results of this review are primarily applicable to older people with moderate to high cardiovascular risk. They may not be applicable to other populations.
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Affiliation(s)
- Jose Agustin Arguedas
- Depto de Farmacologia Clinica, Facultad de Medicina, Universidad de Costa Rica, San Pedro de Montes de Oca, Costa Rica
| | - Viriam Leiva
- Escuela de Enfermeria, Facultad de Medicina, University of Costa Rica, San Jose, Costa Rica
| | - James M Wright
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
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Horby PW, Emberson JR. Hydroxychloroquine for COVID-19: Balancing contrasting claims. Eur J Intern Med 2020; 82:25-26. [PMID: 33243609 PMCID: PMC7682326 DOI: 10.1016/j.ejim.2020.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Peter W Horby
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom.
| | - Jonathan R Emberson
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
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14
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Cook J, Pressler ML, Damle B, Alemayehu D, Knirsch CA. The Weight of Evidence From Electrophysiology, Observational, and Cardiovascular End Point Studies Demonstrates the Safety of Azithromycin. Clin Transl Sci 2020; 14:106-112. [PMID: 32956575 PMCID: PMC7537091 DOI: 10.1111/cts.12867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022] Open
Abstract
Increased use of azithromycin (AZ) in treating infections associated with coronavirus disease 2019 (COVID-19) and reports of increased incidence of prolonged corrected QT (QTc) interval associated with AZ used with hydroxychloroquine prompted us to review the latest evidence in the literature, present additional analyses of human cardiovascular (CV) electrophysiology studies, and to describe sequential steps in research and development that were undertaken to characterize the benefit-risk profile of AZ. Combined QTc findings from electrocardiograms taken during oral and i.v. pharmacokinetic-pharmacodynamic studies of AZ suggest that clinically meaningful QTc prolongation is unlikely. Findings from several observational studies were heterogeneous and not as consistent as results from at least two large randomized controlled trials (RCTs). The QTc findings presented and observational data from studies with large numbers of events are not consistent with either a proarrhythmic action of AZ or an increase in frequency of CV deaths. Well-powered RCTs do not suggest a presence of increased risk of CV or sudden cardiac death after short-term or protracted periods of AZ usage, even in patients at higher risk from pre-existing coronary disease.
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Affiliation(s)
- Jack Cook
- Pfizer Global Research and Development, Groton, Connecticut, USA
| | | | - Bharat Damle
- Pfizer Global Research and Development, New York, New York, USA
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15
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Rocha-Singh KJ. Retrospective Real-World Studies of Paclitaxel and Mortality: Defining the Many Faces of Bias. JACC Cardiovasc Interv 2020; 13:2062-2064. [PMID: 32412550 PMCID: PMC7221362 DOI: 10.1016/j.jcin.2020.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Krishna J Rocha-Singh
- Department of Cardiology, Prairie Heart Institute at HSHS St. John's Hospital, Springfield, Illinois.
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16
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Faulkner SM, Dijk DJ, Drake RJ, Bee PE. Adherence and acceptability of light therapies to improve sleep in intrinsic circadian rhythm sleep disorders and neuropsychiatric illness: a systematic review. Sleep Health 2020; 6:690-701. [PMID: 32173374 DOI: 10.1016/j.sleh.2020.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 01/18/2020] [Accepted: 01/21/2020] [Indexed: 12/26/2022]
Abstract
Sleep problems and circadian misalignment affect health and well-being and are highly prevalent in those with co-morbid neuropsychiatric disorders. Interventions altering light exposure patterns of affected individuals are a promising non-pharmacological treatment option, shown by previous meta-analyses to improve sleep, and often described as minimally invasive. To best translate laboratory-based mechanistic research into effective treatments, acceptability and barriers to adherence should be understood, but these have not yet been systematically evaluated. Here, we examined evidence regarding adherence and acceptability in studies of light or dark interventions using various delivery devices and protocols to improve sleep in intrinsic circadian rhythm sleep-wake disorders and neuropsychiatric illness. Attrition during intervention was low, and reported experiences were largely positive, but measurement and reporting of self-reported experiences, expectations, and adverse effects were poor. Approaches to management and measurement of adherence were varied, and available light monitoring technology appeared under-exploited, as did mobile technology to prompt or track adherence. Based on these findings we suggest recommended reporting items on acceptability and adherence for future investigations. Few studies assessed baseline light exposure patterns, and few personalised interventions. Overall, many applied studies exhibited an approach to light schedule interventions still reminiscent of laboratory protocols; this is unlikely to maximise acceptability and clinical effectiveness. For the next phase of translational research, user acceptability and adherence should receive increased attention during intervention design and study design. We suggest framing light therapies as complex interventions, and emphasise the occupationally embedded (daily activity routine embedded) context in which they occur.
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Affiliation(s)
- Sophie M Faulkner
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, UK.
| | - Derk-Jan Dijk
- Surrey Sleep Research Centre, University of Surrey, Guildford, UK; UK Dementia Research Institute, London, UK
| | - Richard J Drake
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, UK
| | - Penny E Bee
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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17
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Newman CB, Preiss D, Tobert JA, Jacobson TA, Page RL, Goldstein LB, Chin C, Tannock LR, Miller M, Raghuveer G, Duell PB, Brinton EA, Pollak A, Braun LT, Welty FK. Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol 2019; 39:e38-e81. [PMID: 30580575 DOI: 10.1161/atv.0000000000000073] [Citation(s) in RCA: 375] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One in 4 Americans >40 years of age takes a statin to reduce the risk of myocardial infarction, ischemic stroke, and other complications of atherosclerotic disease. The most effective statins produce a mean reduction in low-density lipoprotein cholesterol of 55% to 60% at the maximum dosage, and 6 of the 7 marketed statins are available in generic form, which makes them affordable for most patients. Primarily using data from randomized controlled trials, supplemented with observational data where necessary, this scientific statement provides a comprehensive review of statin safety and tolerability. The review covers the general patient population, as well as demographic subgroups, including the elderly, children, pregnant women, East Asians, and patients with specific conditions such as chronic disease of the kidney and liver, human immunodeficiency viral infection, and organ transplants. The risk of statin-induced serious muscle injury, including rhabdomyolysis, is <0.1%, and the risk of serious hepatotoxicity is ≈0.001%. The risk of statin-induced newly diagnosed diabetes mellitus is ≈0.2% per year of treatment, depending on the underlying risk of diabetes mellitus in the population studied. In patients with cerebrovascular disease, statins possibly increase the risk of hemorrhagic stroke; however, they clearly produce a greater reduction in the risk of atherothrombotic stroke and thus total stroke, as well as other cardiovascular events. There is no convincing evidence for a causal relationship between statins and cancer, cataracts, cognitive dysfunction, peripheral neuropathy, erectile dysfunction, or tendonitis. In US clinical practices, roughly 10% of patients stop taking a statin because of subjective complaints, most commonly muscle symptoms without raised creatine kinase. In contrast, in randomized clinical trials, the difference in the incidence of muscle symptoms without significantly raised creatinine kinase in statin-treated compared with placebo-treated participants is <1%, and it is even smaller (0.1%) for patients who discontinued treatment because of such muscle symptoms. This suggests that muscle symptoms are usually not caused by pharmacological effects of the statin. Restarting statin therapy in these patients can be challenging, but it is important, especially in patients at high risk of cardiovascular events, for whom prevention of these events is a priority. Overall, in patients for whom statin treatment is recommended by current guidelines, the benefits greatly outweigh the risks.
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18
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Tanaka N, Yamamoto Y, Yokoyama Y, Mori T, Hanai K, Babazono T. Temporal trends in the prevalence of albuminuria and reduced eGFR in Japanese patients with type 2 diabetes. Diabetol Int 2019; 10:279-287. [PMID: 31592404 DOI: 10.1007/s13340-019-00392-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 02/22/2019] [Indexed: 01/12/2023]
Abstract
Changes over time have been shown in renal manifestations in individuals with diabetes in the United States; however, whether the trends are shared across ethnicities is unknown. We conducted this single-center serial cross-sectional study to determine temporal changes in albuminuria and reduced kidney function in Japanese patients with type 2 diabetes. This study included adult Japanese patients with type 2 diabetes who first visited our institute between 2004 and 2013. Temporal changes during the 10 years in the frequency of albuminuria ( ≥ 30 mg/g creatinine) and reduced eGFR ( < 60 mL/min/1.73 m2) were analyzed using the univariate and multivariate logistic regression analyses and Granger causality test. 5331 Japanese patients with type 2 diabetes, 1892 women and 3439 men, with the mean age of 56 ± 13 years, were studied. There was no change in the prevalence of albuminuria in the univariate analysis; however, a significantly decreasing trend was observed after adjustment for several covariates. On the other hand, patients with reduced eGFR significantly increased over time, although the statistical significance disappeared after adjustment for the covariates, including levels of serum uric acid and hemoglobin and use of renin-angiotensin inhibitors. The Granger causality test showed that time series for use of RAS inhibitors and BMI had a causative role in time series for reduced eGFR. In conclusion, prevalence of albuminuria decreased and that of reduced eGFR remained stable after adjustment for clinical characteristics in Japanese patients with type 2 diabetes during the last decade.
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Affiliation(s)
- Nobue Tanaka
- Department of Medicine, Diabetes Center, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Yui Yamamoto
- Department of Medicine, Diabetes Center, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Yoichi Yokoyama
- Department of Medicine, Diabetes Center, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Tomomi Mori
- Department of Medicine, Diabetes Center, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Ko Hanai
- Department of Medicine, Diabetes Center, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Tetsuya Babazono
- Department of Medicine, Diabetes Center, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
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19
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Bergman J, Nordström A, Hommel A, Kivipelto M, Nordström P. Bisphosphonates and mortality: confounding in observational studies? Osteoporos Int 2019; 30:1973-1982. [PMID: 31367949 PMCID: PMC6795608 DOI: 10.1007/s00198-019-05097-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/15/2019] [Indexed: 02/01/2023]
Abstract
UNLABELLED Numerous observational studies suggest that bisphosphonates reduce mortality. This study showed that bisphosphonate use is associated with lower mortality within days of treatment, although the association was not significant until the second week. Such an early association is consistent with confounding, although an early treatment effect cannot be ruled out. INTRODUCTION The purpose of this study was to examine whether confounding explains why numerous observational studies show that bisphosphonate use is associated with lower mortality. To this end, we examined how soon after treatment initiation a lower mortality rate can be observed. We hypothesized that, due to confounding, the association would be observed immediately. METHODS This was a retrospective cohort study of hip fracture patients discharged from Swedish hospitals between 1 July 2006 and 31 December 2015. The data covered 260,574 hip fracture patients and were obtained from the Swedish Hip Fracture Register and national registers. Of the 260,574 patients, 49,765 met all eligibility criteria and 10,178 were pair matched (bisphosphonate users to controls) using time-dependent propensity scores. The matching variables were age, sex, diagnoses, prescription medications, type of hip fracture, type of surgical procedure, known or suspected dementia, and physical functioning status. RESULTS Over a median follow-up of 2.8 years, 2922 of the 10,178 matched patients died. The mortality rate was 7.9 deaths per 100 person-years in bisphosphonate users and 9.4 deaths in controls, which corresponded to a 15% lower mortality rate in bisphosphonate users (hazard ratio 0.85, 95% confidence interval 0.79-0.91). The risk of death was lower in bisphosphonate users from day 6 of treatment, although the association was not significant until the second week. CONCLUSION Bisphosphonate use was associated with lower mortality within days of treatment initiation. This finding is consistent with confounding, although an early treatment effect cannot be ruled out.
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Affiliation(s)
- J Bergman
- Unit of Geriatric Medicine, Department of Community Medicine and Rehabilitation, Umeå University, 90187, Umeå, Sweden
| | - A Nordström
- Section of Sustainable Health, Department of Public Health and Clinical Medicine, Umeå University, 90187, Umeå, Sweden
- School of Sport Sciences, UiT Arctic University of Norway, Postboks 1621, 9509, Alta, Norway
| | - A Hommel
- Department of Care Sciences, Malmö University, 20506, Malmö, Sweden
| | - M Kivipelto
- Division of Clinical geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Plan 7, 14183, Huddinge, Sweden
- Theme Aging, Karolinska Univeristy Hospital, 14186, Stockholm, Sweden
- Research and Development Unit, Stockholm Sjukhem, Mariebergsgatan 22, 11219, Stockholm, Sweden
| | - P Nordström
- Unit of Geriatric Medicine, Department of Community Medicine and Rehabilitation, Umeå University, 90187, Umeå, Sweden.
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20
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McMurray JJV. Only Trials Tell the Truth About Treatment Effects. J Am Coll Cardiol 2019; 71:2640-2642. [PMID: 29880123 DOI: 10.1016/j.jacc.2018.04.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/12/2018] [Indexed: 11/15/2022]
Affiliation(s)
- John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
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21
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Approaches to Address Premature Death of Patients When Assessing Patterns of Use of Health Care Services After an Index Event. Med Care 2019; 56:619-625. [PMID: 29877956 DOI: 10.1097/mlr.0000000000000923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Studies of the use of health care after the onset of disease are important for assessing quality of care, treatment disparities, and guideline compliance. Cohort definition and analysis method are important considerations for the generalizability and validity of study results. We compared different approaches for cohort definition (restriction by survival time vs. comorbidity score) and analysis method [Kaplan-Meier (KM) vs. competing risk] when assessing patterns of guideline adoption in elderly patients. METHODS Medicare beneficiaries aged 65-95 years old who had an acute myocardial infarction (AMI) in 2008 were eligible for this study. Beneficiaries with substantial frailty or an AMI in the prior year were excluded. We compared KM with competing risk estimates of guideline adoption during the first year post-AMI. RESULTS At 1-year post-AMI, 14.2% [95% confidence interval (CI), 14.0%-14.5%) of beneficiaries overall initiated cardiac rehabilitation when using competing risk analysis and 15.1% (95% CI, 14.8%-15.3%) from the KM analysis. Guideline medication adoption was estimated as 52.3% (95% CI, 52.0%-52.7%) and 53.4% (95% CI, 53.1%-53.8%) for competing risk and KM methods, respectively. Mortality was 17.0% (95%CI, 16.8%-17.3%) at 1 year post-AMI. The difference in cardiac rehabilitation initiation at 1-year post-AMI from the overall population was 0.1%, 1.7%, and 1.9% compared with 30-day survivor, 1-year survivor, and comorbidity-score restricted populations, respectively. CONCLUSIONS In this study, the KM method consistently overestimated the competing risk method. Competing risk approaches avoid unrealistic mortality assumptions and lead to interpretations of estimates that are more meaningful.
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22
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Vonbank A, Drexel H, Agewall S, Lewis BS, Dopheide JF, Kjeldsen K, Ceconi C, Savarese G, Rosano G, Wassmann S, Niessner A, Schmidt TA, Saely CH, Baumgartner I, Tamargo J. Reasons for disparity in statin adherence rates between clinical trials and real-world observations: a review. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 4:230-236. [PMID: 30099530 DOI: 10.1093/ehjcvp/pvy028] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/06/2018] [Indexed: 11/14/2022]
Abstract
With statins, the reported rate of adverse events differs widely between randomized clinical trials (RCTs) and observations in clinical practice, the rates being 1-2% in RCTs vs. 10-20% in the so-called real world. One possible explanation is the claim that RCTs mostly use a run-in period with a statin. This would exclude intolerant patients from remaining in the trial and therefore favour a bias towards lower rates of intolerance. We here review data from RCTs with more than 1000 participants with and without a run-in period, which were included in the Cholesterol Treatment Trialists Collaboration. Two major conclusions arise: (i) the majority of RCTs did not have a test dose of a statin in the run-in phase. (ii) A test dose in the run-in phase was not associated with a significantly improved adherence rate within that trial when compared to trials without a test dose. Taken together, the RCTs of statins reviewed here do not suggest a bias towards an artificially higher adherence rate because of a run-in period with a test dose of the statin. Other possible explanations for the apparent disparity between RCTs and real-world observations are also included in this review albeit mostly not supported by scientific data.
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Affiliation(s)
- Alexander Vonbank
- Department of Medicine I, Academic Teaching Hospital Feldkirch, Feldkirch, Austria.,Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria.,Private University of the Principality of Liechtenstein, Triesen, Liechtenstein
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria.,Private University of the Principality of Liechtenstein, Triesen, Liechtenstein.,Drexel University College of Medicine, Philadelphia, PA, USA.,Division of Angiology, Swiss Cardiovascular Center, University Hospital Bern, Switzerland
| | - Stefan Agewall
- Department of Cardiology, Ullevål, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Sciences, Søsterhjemmet, University of Oslo, Oslo, Norway
| | - Basil S Lewis
- Lady Davis Carmel Medical Center, Haifa, Israel.,Technion-Israel Institute of Technology, Ruth and Bruce Rappaport School of Medicine, Haifa, Israel
| | - Joern F Dopheide
- Division of Angiology, Swiss Cardiovascular Center, University Hospital Bern, Switzerland
| | - Keld Kjeldsen
- Division of Cardiology, Department of Medicine, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Claudio Ceconi
- Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Gianluigi Savarese
- Department of Medicine, Cardiology Division, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Giuseppe Rosano
- Department of Medical Sciences, Irccs San Raffaele Hospital, Rome, Italy
| | - Sven Wassmann
- Cardiology Pasing, Munich, Germany and University of the Saarland, Homburg, Saar, Germany
| | - Alexander Niessner
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Andersen Schmidt
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.,Department of Emergency Medicine, Holbaek Hospital, University of Copenhagen, Denmark
| | - Christoph H Saely
- Department of Medicine I, Academic Teaching Hospital Feldkirch, Feldkirch, Austria.,Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria.,Private University of the Principality of Liechtenstein, Triesen, Liechtenstein.,Division of Angiology, Swiss Cardiovascular Center, University Hospital Bern, Switzerland
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, University Hospital Bern, Switzerland
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Ciudad Universitaria, Madrid, Spain
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23
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Secrest MH, Platt RW, Dormuth CR, Chateau D, Targownik L, Nie R, Doyle CM, Dell'Aniello S, Filion KB. Extreme restriction design as a method for reducing confounding by indication in pharmacoepidemiologic research. Pharmacoepidemiol Drug Saf 2019; 29 Suppl 1:26-34. [DOI: 10.1002/pds.4708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/27/2018] [Accepted: 11/14/2018] [Indexed: 01/24/2023]
Affiliation(s)
- Matthew H. Secrest
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
| | - Robert W. Platt
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill University Montreal Canada
- Department of PediatricsMcGill University Montreal Canada
| | - Colin R. Dormuth
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of MedicineUniversity of British Columbia Vancouver Canada
| | - Dan Chateau
- Department of Community Health Sciences, Manitoba Centre for Health Policy, College of Medicine, Faculty of Health SciencesUniversity of Manitoba Winnipeg Canada
| | - Laura Targownik
- Department of Community Health Sciences, Manitoba Centre for Health Policy, College of Medicine, Faculty of Health SciencesUniversity of Manitoba Winnipeg Canada
| | - Rui Nie
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
| | - Carla M. Doyle
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill University Montreal Canada
| | - Sophie Dell'Aniello
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
| | - Kristian B. Filion
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill University Montreal Canada
- Division of Clinical Epidemiology, Department of MedicineMcGill University Montreal Canada
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24
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Chiang JI, Jani BD, Mair FS, Nicholl BI, Furler J, O’Neal D, Jenkins A, Condron P, Manski-Nankervis JA. Associations between multimorbidity, all-cause mortality and glycaemia in people with type 2 diabetes: A systematic review. PLoS One 2018; 13:e0209585. [PMID: 30586451 PMCID: PMC6306267 DOI: 10.1371/journal.pone.0209585] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 12/08/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction Type 2 diabetes (T2D) is a major health priority worldwide and the majority of people with diabetes live with multimorbidity (MM) (the co-occurrence of ≥2 chronic conditions). The aim of this systematic review was to explore the association between MM and all-cause mortality and glycaemic outcomes in people with T2D. Methods The search strategy centred on: T2D, MM, comorbidity, mortality and glycaemia. Databases searched: MEDLINE, EMBASE, CINAHL Complete, The Cochrane Library, and SCOPUS. Restrictions included: English language, quantitative empirical studies. Two reviewers independently carried out: abstract and full text screening, data extraction, and quality appraisal. Disagreements adjudicated by a third reviewer. Results Of the 4882 papers identified; 41 met inclusion criteria. The outcome was all-cause mortality in 16 studies, glycaemia in 24 studies and both outcomes in one study. There were 28 longitudinal cohort studies and 13 cross-sectional studies, with the number of participants ranging from 96–892,223. Included studies were conducted in high or upper-middle-income countries. Fifteen of 17 studies showed a statistically significant association between increasing MM and higher mortality. Ten of 14 studies showed no significant associations between MM and HbA1c. Four of 14 studies found higher levels of MM associated with higher HbA1c. Increasing MM was significantly associated with hypoglycaemia in 9/10 studies. There was no significant association between MM and fasting glucose (one study). No studies explored effects on glycaemic variability. Conclusions This review demonstrates that MM in T2D is associated with higher mortality and hypoglycaemia, whilst evidence regarding the association with other measures of glycaemic control is mixed. The current single disease focused approach to management of T2D seems inappropriate. Our findings highlight the need for clinical guidelines to support a holistic approach to the complex care needs of those with T2D and MM, accounting for the various conditions that people with T2D may be living with. Systematic review registration International Prospective Register of Systematic Reviews CRD42017079500
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Affiliation(s)
- Jason I. Chiang
- Department of General Practice, University of Melbourne, Melbourne, Australia
- * E-mail:
| | - Bhautesh Dinesh Jani
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Frances S. Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Barbara I. Nicholl
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - John Furler
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - David O’Neal
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Melbourne, Australia
| | - Alicia Jenkins
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Patrick Condron
- Brownless Biomedical Library, University of Melbourne, Melbourne, Australia
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Increased longevity in older users of postmenopausal estrogen therapy: the Leisure World Cohort Study. Menopause 2018; 25:1256-1261. [PMID: 30358721 DOI: 10.1097/gme.0000000000001227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To examine the effect of postmenopausal estrogen therapy (ET), including duration and recency of use, on all-cause mortality in older women. DESIGN As part of a prospective cohort study of residents of a California retirement community begun in the early 1980s, Leisure World Cohort women (median age, 73 y) completed a postal health survey including details on ET use and were followed up for 22 years (1981-2003). Age- and multivariate-adjusted risk ratios (RR) and 95% CIs were calculated using proportional hazard regression. RESULTS Of the 8,801 women, 6,626 died during follow-up (median age, 88 y). ET users had an age-adjusted mortality rate of 52.9 per 1,000 person-years compared with 56.5 among lifetime nonusers (RR = 0.91; 95% CI, 0.87-0.96). Risk of death decreased with both increasing duration of ET and decreasing years since last use (P for trend < 0.001). The risk was lowest among long-term (≥15 y) users (RR = 0.83; 95% CI, 0.74-0.93 for 15-19 y and RR = 0.87; 95% CI, 0.80-0.94 for 201 y). For long-term users, the age-adjusted mortality rate was 50.4 per 1,000 person-years. Lower-dose users (≤0.625 mg) had a slightly better survival rate than higher-dose users (RR = 0.84; 95% CI, 0.78-0.91 vs RR = 0.91; 95% CI, 0.83-0.97). Risk did not differ by route of administration (P = 0.56). Further adjustment for potential confounders had little effect on the observed RRs for ET. CONCLUSION Long-term ET is associated with lower all-cause mortality in older women.
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Asano Y. How to Eliminate Uncertainty in Clinical Medicine – Clues from Creation of Mathematical Models Followed by Scientific Data Mining. EBioMedicine 2018; 34:12-13. [PMID: 30005950 PMCID: PMC6116344 DOI: 10.1016/j.ebiom.2018.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 07/02/2018] [Indexed: 11/26/2022] Open
Affiliation(s)
- Yoshihiro Asano
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
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Statin Safety: What Every Health Care Provider Needs to Know. CURRENT CARDIOVASCULAR RISK REPORTS 2018. [DOI: 10.1007/s12170-018-0565-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chazapis M, Gilhooly D, Smith A, Myles P, Haller G, Grocott M, Moonesinghe S. Perioperative structure and process quality and safety indicators: a systematic review. Br J Anaesth 2018; 120:51-66. [DOI: 10.1016/j.bja.2017.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 12/12/2022] Open
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Improving Guideline Compliance in Australia With a National Percutaneous Coronary Intervention Outcomes Registry. Heart Lung Circ 2017; 26:1303-1309. [DOI: 10.1016/j.hlc.2017.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 11/19/2016] [Accepted: 01/06/2017] [Indexed: 11/19/2022]
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Ji L, Zhang P, Zhu D, Li X, Ji J, Lu J, Guo X, Jia W, Weng J, Wu Y, Yang W, Zou D, Zhou Z, Pan C, Gao Y, Garg SK. Observational Registry of Basal Insulin Treatment (ORBIT) in patients with type 2 diabetes uncontrolled with oral antihyperglycaemic drugs: Real-life use of basal insulin in China. Diabetes Obes Metab 2017; 19:822-830. [PMID: 28105735 DOI: 10.1111/dom.12886] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 01/10/2017] [Accepted: 01/17/2017] [Indexed: 12/12/2022]
Abstract
AIMS To examine treatment patterns following basal insulin (BI) introduction in type 2 diabetes mellitus (T2DM) patients under real-world conditions across China. MATERIALS AND METHODS Overall, 18 995 patients inadequately controlled (HbA1c ≥ 53 mmol/mol [7%]) with oral antihyperglycaemic drugs (OADs) and willing to receive BI treatment were registered at 209 hospitals and followed at baseline (visit 1), 3 months (visit 2) and 6 months (visit 3). Type of BI was initiated at physicians' discretion. RESULTS Retention with BI therapy at 6 months was 75.6%. Use of long-acting BI predominated, with insulin glargine accounting for 71%, detemir 13% and Neutral Protamine Hagedorn (NPH) insulin 16%. Over 70% of long-acting users maintained the same initial BI at visit 3, while 40% of NPH users switched treatment and 24.4% of participants initiated BI with prandial insulin. The initial mean (± SD) dose of BI and total insulin was 0.18 ± 0.07 and 0.25 ± 0.19 IU/kg, respectively, with a mean increase of daily dose by 0.03 and 0.02 IU/kg after 6 months, respectively. Only 56.6% of insulin users reported dose titration at visit 3. Mean HbA1c was 81 mmol/mol (9.6%) at baseline and 57 mmol/mol (7.4%) at 6 months. The frequency of hypoglycaemia was 1.61 and 2.07 episodes/patient-year at baseline and 6 months, respectively. CONCLUSIONS In real-world clinical settings, add-on BI therapy in T2DM patients is associated with significant improvement in glycaemic control without overtly compromising safety related to hypoglycaemia and weight gain. Evolution of insulin treatment regimens varied among patients, but dose titration was suboptimal. More active BI dose titration might further improve glycaemic outcome in patients receiving BI therapy. VIDEO ABSTRACT A free Video Abstract to accompany this article is available at https://vimeo.com/212655959.
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Affiliation(s)
- Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Puhong Zhang
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Dongshan Zhu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Xian Li
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Jiachao Ji
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Juming Lu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Xiaohui Guo
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Weiping Jia
- Department of Endocrinology and Metabolism, Shanghai Sixth Hospital, Shanghai, China
| | - Jianping Weng
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Wenying Yang
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Dajin Zou
- Department of Endocrinology, The Second Military Medical University, Shanghai, China
| | - Zhiguang Zhou
- Department of Endocrinology and Metabolism, Xiangya Second Hospital, Changsha, China
| | - Changyu Pan
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Yan Gao
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Satish K Garg
- Barbara Davis Center for Diabetes, University of Colorado Denver, Denver, Colorado
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Martinez L, Penfornis A, Gautier JF, Eschwège E, Charpentier G, Bouzidi A, Gourdy P. Effectiveness and Persistence of Liraglutide Treatment Among Patients with Type 2 Diabetes Treated in Primary Care and Specialist Settings: A Subgroup Analysis from the EVIDENCE Study, a Prospective, 2-Year Follow-up, Observational, Post-Marketing Study. Adv Ther 2017; 34:674-685. [PMID: 28138803 PMCID: PMC5350193 DOI: 10.1007/s12325-017-0476-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Indexed: 11/24/2022]
Abstract
Introduction The objective of this subgroup analysis is to investigate the effectiveness of liraglutide in people with type 2 diabetes (T2D) treated within the primary care physician (PCP) and specialist care settings. Methods EVIDENCE is a prospective, observational study of 3152 adults with T2D recently starting or about to start liraglutide treatment in France. We followed patients in the PCP and specialist settings for 2 years to evaluate the effectiveness of liraglutide in glycemic control and body weight reduction. Furthermore, we evaluated the changes in combined antihyperglycemic treatments, the reasons for prescribing liraglutide, patient satisfaction, and safety of liraglutide in these two treatment settings. Results After 2 years of follow-up, 477 out of 1209 (39.0%) of PCP and 297 out of 1398 (21.2%) of specialist-treated patients still used liraglutide and maintained the glycated hemoglobin (HbA1c) target of <7.0%. Significant reductions from baseline were observed in both PCP- and specialist-treated cohorts in mean HbA1c (−1.22% and −0.8%, respectively), fasting plasma glucose (FPG) concentration (−39 and −23 mg/dL), body weight (−4.4 and −3.8 kg), and body mass index (BMI) (−1.5 and −1.4 kg/m2), all p < 0.0001. Reductions in HbA1c and FPG were significantly greater among PCP- compared with specialist-treated patients, p < 0.0001 for both. Patient treatment satisfaction was also significantly increased in both cohorts. Reported gastrointestinal adverse events were less frequent among PCP-treated patients compared with specialist-treated patients (4.5% vs. 16.1%). Conclusion Despite differences in demography and clinical characteristics of patients treated for T2D in PCP and specialty care, greater reduction in HbA1c and increased glycemic control durability were observed with liraglutide in primary care, compared with specialist care. These data suggest that liraglutide treatment could benefit patients in primary care by delaying the need for further treatment intensification. Trial Registration ClinicalTrials.gov identifier, NCT01226966. Funding Novo Nordisk A/S. Electronic supplementary material The online version of this article (doi:10.1007/s12325-017-0476-0) contains supplementary material, which is available to authorized users.
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Eriksson SE. Secondary prophylactic treatment and long-term prognosis after TIA and different subtypes of stroke. A 25-year follow-up hospital-based observational study. Brain Behav 2017; 7:e00603. [PMID: 28127521 PMCID: PMC5256186 DOI: 10.1002/brb3.603] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/29/2016] [Accepted: 10/10/2016] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To assess long-term prognosis after transient ischemic attack (TIA)/subtypes of stroke relative to secondary prophylactic treatment(s) given. MATERIALS AND METHODS Retro/prospective follow-up of patients hospitalized in the Stroke Unit or in the Department of Neurology, Linköping, in 1986 and followed up to Feb. 2011. RESULTS A total of 288 men were followed up for 2254 years (mean 7.8 years) and 261 women for 1984 years (mean 7.6 years). In men, the distribution to anticoagulants (AC) (warfarin treatment) was 18%, antiplatelet therapy (APT) usually ASA 75 mg/day 54%, untreated 27%, unknown 2%. In women, the distribution to AC was 15%, APT 60%, untreated 23%, unknown 2%, respectively. Mortality rates at 1 year, 10 years, and 25 years for men were 21%, 67%, and 93%, respectively, versus the rates in women of 24%, 71%, and 90%, respectively. Survival curves showed markedly increased risk of death compared to the normal population. AC treatment was more favorable for men regarding the annual risk of stroke, compared with APT (9.4% vs. 9.8%), as well as the risks of MI, (5.6% vs. 6.7%), and death (8.1% vs. 10.3%), compared to women for stroke (11.6% vs. 8.8%) and MI (5.3% vs. 3.7%) but not for death (8.3% vs. 8.4%). The risk of fatal bleeding was 0.86% annually on AC compared to 0.17% on APT. According to Cox regression analysis included patients with TIA/ischemic stroke, first-line treatment had beneficial effects on survival: AC OR 0.67 (0.5-0.9), APT 0.67 (0.52-0.88) versus untreated. CONCLUSIONS Patients with a history of TIA/stroke had a higher mortality rate versus controls, providing support for both primary and secondary prophylaxis regarding vascular risk factors for death. This study also provided support for secondary prophylactic treatment with either AC or ASA (75 mg once daily) to reduce the vascular risk of death unless there are contraindications.
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Affiliation(s)
- Sven-Erik Eriksson
- Division of Neurology Department of Medicine Falun Hospital Falun Sweden
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Yun JS, Ko SH. Risk Factors and Adverse Outcomes of Severe Hypoglycemia in Type 2 Diabetes Mellitus. Diabetes Metab J 2016; 40:423-432. [PMID: 27766794 PMCID: PMC5167706 DOI: 10.4093/dmj.2016.40.6.423] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/24/2016] [Indexed: 12/15/2022] Open
Abstract
Hypoglycemia has been considered as a major barrier to achieving the proper glycemic target in type 2 diabetes mellitus patients. In particular, severe hypoglycemia (SH), which is defined as a hypoglycemic episode requiring the assistance of another person to raise the patient's glucose level, is a serious complication of diabetes because of its possible fatal outcomes. Recently, the recommendations for diabetes care have emphasized a patient-centered approach, considering the individualized patient factors including hypoglycemia. Many studies have been performed which analyzed the risk factors and clinical outcomes for SH. From the studies, researchers recommend that targeting a less stringent glycosylated hemoglobin level and selecting a safer class of drugs for hypoglycemia are appropriate for patients with a high risk of SH. Also, careful clinical attention to prevent hypoglycemia, including intensive education, is necessary to minimize the risk of SH and SH-related fatal outcomes.
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Affiliation(s)
- Jae Seung Yun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Seung Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea.
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Collins R, Reith C, Emberson J, Armitage J, Baigent C, Blackwell L, Blumenthal R, Danesh J, Smith GD, DeMets D, Evans S, Law M, MacMahon S, Martin S, Neal B, Poulter N, Preiss D, Ridker P, Roberts I, Rodgers A, Sandercock P, Schulz K, Sever P, Simes J, Smeeth L, Wald N, Yusuf S, Peto R. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016; 388:2532-2561. [PMID: 27616593 DOI: 10.1016/s0140-6736(16)31357-5] [Citation(s) in RCA: 1169] [Impact Index Per Article: 146.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/11/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023]
Abstract
This Review is intended to help clinicians, patients, and the public make informed decisions about statin therapy for the prevention of heart attacks and strokes. It explains how the evidence that is available from randomised controlled trials yields reliable information about both the efficacy and safety of statin therapy. In addition, it discusses how claims that statins commonly cause adverse effects reflect a failure to recognise the limitations of other sources of evidence about the effects of treatment. Large-scale evidence from randomised trials shows that statin therapy reduces the risk of major vascular events (ie, coronary deaths or myocardial infarctions, strokes, and coronary revascularisation procedures) by about one-quarter for each mmol/L reduction in LDL cholesterol during each year (after the first) that it continues to be taken. The absolute benefits of statin therapy depend on an individual's absolute risk of occlusive vascular events and the absolute reduction in LDL cholesterol that is achieved. For example, lowering LDL cholesterol by 2 mmol/L (77 mg/dL) with an effective low-cost statin regimen (eg, atorvastatin 40 mg daily, costing about £2 per month) for 5 years in 10 000 patients would typically prevent major vascular events from occurring in about 1000 patients (ie, 10% absolute benefit) with pre-existing occlusive vascular disease (secondary prevention) and in 500 patients (ie, 5% absolute benefit) who are at increased risk but have not yet had a vascular event (primary prevention). Statin therapy has been shown to reduce vascular disease risk during each year it continues to be taken, so larger absolute benefits would accrue with more prolonged therapy, and these benefits persist long term. The only serious adverse events that have been shown to be caused by long-term statin therapy-ie, adverse effects of the statin-are myopathy (defined as muscle pain or weakness combined with large increases in blood concentrations of creatine kinase), new-onset diabetes mellitus, and, probably, haemorrhagic stroke. Typically, treatment of 10 000 patients for 5 years with an effective regimen (eg, atorvastatin 40 mg daily) would cause about 5 cases of myopathy (one of which might progress, if the statin therapy is not stopped, to the more severe condition of rhabdomyolysis), 50-100 new cases of diabetes, and 5-10 haemorrhagic strokes. However, any adverse impact of these side-effects on major vascular events has already been taken into account in the estimates of the absolute benefits. Statin therapy may cause symptomatic adverse events (eg, muscle pain or weakness) in up to about 50-100 patients (ie, 0·5-1·0% absolute harm) per 10 000 treated for 5 years. However, placebo-controlled randomised trials have shown definitively that almost all of the symptomatic adverse events that are attributed to statin therapy in routine practice are not actually caused by it (ie, they represent misattribution). The large-scale evidence available from randomised trials also indicates that it is unlikely that large absolute excesses in other serious adverse events still await discovery. Consequently, any further findings that emerge about the effects of statin therapy would not be expected to alter materially the balance of benefits and harms. It is, therefore, of concern that exaggerated claims about side-effect rates with statin therapy may be responsible for its under-use among individuals at increased risk of cardiovascular events. For, whereas the rare cases of myopathy and any muscle-related symptoms that are attributed to statin therapy generally resolve rapidly when treatment is stopped, the heart attacks or strokes that may occur if statin therapy is stopped unnecessarily can be devastating.
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Affiliation(s)
- Rory Collins
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Christina Reith
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jonathan Emberson
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane Armitage
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Colin Baigent
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Lisa Blackwell
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Roger Blumenthal
- Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John Danesh
- MRC/BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - David DeMets
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Stephen Evans
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, University of London, London, UK
| | - Malcolm Law
- Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Stephen MacMahon
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Seth Martin
- Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bruce Neal
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Neil Poulter
- International Centre for Circulatory Health & Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - David Preiss
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paul Ridker
- Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, University of London, London, UK
| | - Anthony Rodgers
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kenneth Schulz
- FHI 360, University of North Carolina School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Peter Sever
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - John Simes
- National Health and Medical Research Council Clinical Trial Centre, University of Sydney, Sydney, Australia
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, University of London, London, UK
| | - Nicholas Wald
- Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Richard Peto
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Judge PK, Reschen ME, Haynes R, Sharples EJ. Outcomes of Elderly Patients with Anti-Neutrophil Cytoplasmic Autoantibody-Associated Vasculitis Treated with Immunosuppressive Therapy. Nephron Clin Pract 2016; 133:223-31. [PMID: 27433990 DOI: 10.1159/000447018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 05/19/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV) is a cause of biopsy-proven acute kidney injury, more common in the elderly. Treatment requires immunosuppression, which can have significant toxic effects. The aim of this study was to assess whether morbidity and mortality that are associated with immunosuppression for AAV varied with age. METHODS A retrospective review of 232 patients given induction therapy with prednisolone and cyclophosphamide was conducted. Information was collected on baseline characteristics (including requirement for dialysis at presentation) and the occurrence of leukopenia, infection, end-stage renal disease and death during follow-up. RESULTS Median follow-up was 51 months. Older patients (aged ≥70 years) were treated with lower total cyclophosphamide doses than those aged <70 years (mean 7.3 g (SD 4.4) vs. 10.7 g (SD 7.4), respectively). Increasing age was associated with an increased risk of leukopenia (odds ratio (OR) 1.50; 95% confidence interval (CI) 1.20-1.86; p < 0.001), and older patients were more likely to develop infections in the first year (OR 1.87; 95% CI 1.1-3.2). Older patients were also significantly more likely to require dialysis at presentation (OR 1.66; 95% CI 1.13-2.5) and longer term. After multivariable adjustment, age and requirement for dialysis at presentation were significant predictors of death (hazard ratio (HR) per year of age 1.07; 95% CI 1.03-1.11; p < 0.001 and HR 2.2; 95% CI 1.10-4.38; p = 0.03, respectively). CONCLUSIONS Among patients treated with prednisolone and cyclophosphamide, increasing age and dialysis dependency were associated with worse survival. Older patients were more likely to develop treatment-related complications despite lower cumulative doses of immunosuppression. Morbidity and mortality associated with treatment must therefore be carefully balanced against that associated with the disease process itself.
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Affiliation(s)
- Parminder K Judge
- Oxford Kidney Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Tobert JA, Newman CB. The nocebo effect in the context of statin intolerance. J Clin Lipidol 2016; 10:739-747. [DOI: 10.1016/j.jacl.2016.05.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/03/2016] [Accepted: 05/07/2016] [Indexed: 02/08/2023]
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de Lemos ML, Taylor SC, Barnett JB, Hu F, Levin A, Moravan V, O'Reilly SE. Renal safety of 1-hour pamidronate infusion for breast cancer and multiple myeloma patients: comparison between clinical trials and population-based database. J Oncol Pharm Pract 2016; 12:193-9. [PMID: 17156591 DOI: 10.1177/1078155206073520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose. The American Society of Clinical Oncology recommends infusion of pamidronate over 2 hours to avoid renal deterioration, although there are data to suggest that 1-hour infusions may be safe.Methods, Prevalence of renal deterioration with 1-hour pamidronate infusions from a population database was compared to renal deterioration with 2-hour pamidronate infusions, in randomised, controlled, trials. A cost-minimisation analysis, comparing the 1-and 2-hour pamidronate infusions, and the 15-minute infusion of zoledronic acid, was performed with a sensitivity analysis that varied the opportunity cost of time in the treatment room.Results. Renal deterioration occurred in 7.7% of 169 patients with multiple myeloma and metastatic breast cancer. There is no evidence that this differs from the 10% reported in randomised, controlled, trials (one-tailed binomial test, P=0.3874). A subgroup analysis showed that renal deterioration occurred in 15 and 1.1% of patients with multiple myeloma and metastatic breast cancer, respectively. The median increase in serum creatinine was 13 and 7% in the multiple myeloma and breast cancer groups, respectively. The respective costs/dose (drug/ labour/supplies) of pamidronate and zoledronic acid are $325 and $610. Cost neutrality occurs if the opportunity cost of chair time is $6.33/ minute for pamidronate 1-hour versus zoledronic acid, and $2.71/minute for pamidronate 2-hour versus zoledronic acid. If a median $4/minute is used, the respective costs of pamidronate 1-hour, 2-hour, and zoledronic acid infusions are $685, $925, and $790/cycle.Conclusions. Prevalence of renal deterioration with 1-hour pamidronate infusions from a population database was not significantly different to 2-hour pamidronate infusions in clinical trials. Our findings suggest further support for the safety of 1-hour pamidronate infusions. Pamidronate via 1-hour infusion is less expensive than zoledronic acid.
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Affiliation(s)
- Mário L de Lemos
- Provincial Systemic Therapy Program, British Columbia Cancer Agency, Vancouver, BC, Canada.
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Meta-Analysis of Anticoagulation Use, Stroke, Thromboembolism, Bleeding, and Mortality in Patients With Atrial Fibrillation on Dialysis. Am J Cardiol 2016; 117:1934-41. [PMID: 27237624 DOI: 10.1016/j.amjcard.2016.03.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/17/2016] [Accepted: 03/18/2016] [Indexed: 12/18/2022]
Abstract
Atrial fibrillation (AF) is common in patients on dialysis. Although randomized trials of anticoagulation for AF have demonstrated striking reductions in stroke, these trials did not recruit patients on dialysis. We thus undertook this systematic review and meta-analysis of observational studies including patients with AF on dialysis that reported associations of anticoagulation use. Twenty studies involving 529,741 subjects and 31,321 patients with AF on dialysis were identified. Anticoagulation was associated with a 45% (95% CI 13% to 88%) increased risk of any stroke, reflecting a nonsignificant 13% (95% CI -4% to 34%) increased ischemic stroke risk and 38% (95% CI 3% to 85%) increased hemorrhagic stroke risk. There was also a 44% (95% CI 38% to 56%) lower risk of any thromboembolism, and a 31% (95% CI 12% to 53%) increased risk of any bleeding but no clear association with cardiovascular death (relative risk 0.99, 95% CI 0.86 to 1.15) or all-cause mortality (relative risk 0.97, 95% CI 0.90 to 1.04). Incident event rates were similar or worse in patients on anticoagulation. In conclusion, these observational analyses provide little supporting evidence of benefit, and instead suggest harm, from anticoagulation in patients on dialysis with AF. These results raise the possibility that the effects of anticoagulation in patients with AF on dialysis may not be similar to the clear benefit of anticoagulation seen in patients with AF without end-stage renal disease. Randomized trials are required to definitively evaluate the safety and efficacy of anticoagulation for AF in the dialysis setting.
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Reith C, Blackwell L, Emberson J, Mihaylova B, Armitage J, Fulcher J, Keech A, Simes J, Baigent C, Collins R. Protocol for analyses of adverse event data from randomized controlled trials of statin therapy. Am Heart J 2016; 176:63-9. [PMID: 27264221 PMCID: PMC4906243 DOI: 10.1016/j.ahj.2016.01.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/16/2016] [Indexed: 01/14/2023]
Abstract
The Cholesterol Treatment Trialists' (CTT) Collaboration was originally established to conduct individual participant data meta-analyses of major vascular events, cause-specific mortality, and site-specific cancers in large, long-term, randomized trials of statin therapy (and other cholesterol-modifying treatments). The results of the trials of statin therapy and their associated meta-analyses have shown that statins significantly reduce the risk of major vascular events without any increase in the risk of nonvascular causes of death or of site-specific cancer, but do produce small increases in the incidence of myopathy, diabetes, and, probably, hemorrhagic stroke. The CTT Collaboration has not previously sought data on other outcomes, and so a comprehensive meta-analysis of all adverse events recorded in each of the eligible trials has not been conducted. This protocol prospectively describes plans to extend the CTT meta-analysis data set so as to provide a more complete understanding of the nature and magnitude of any other effects of statin therapy.
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van der Molen T, Postma DS, Martin RJ, Herings RMC, Overbeek JA, Thomas V, Miglio C, Dekhuijzen R, Roche N, Guilbert T, Israel E, van Aalderen W, Hillyer EV, van Rysewyk S, Price DB. Effectiveness of initiating extrafine-particle versus fine-particle inhaled corticosteroids as asthma therapy in the Netherlands. BMC Pulm Med 2016; 16:80. [PMID: 27184175 PMCID: PMC4869182 DOI: 10.1186/s12890-016-0234-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 04/27/2016] [Indexed: 11/25/2022] Open
Abstract
Background Most randomised clinical trials typically exclude a significant proportion of asthma patients, including those at higher risk of adverse events, with comorbidities, obesity, poor inhaler technique and adherence, or smokers. However, these patients might differentially benefit from extrafine-particle inhaled corticosteroids (ICS). This matched cohort, database study, compared the effectiveness of extrafine-particle with fine-particle ICS in a real-life population initiating ICS therapy in the Netherlands. Methods Data were from the Pharmo Database Network, comprising pharmacy and hospital discharge records, representative of 20 % of the Dutch population. The study population included patients aged 12 − 60, with a General Practice-recorded diagnosis for asthma (International Classification of Primary Care code R96), when available, ≥2 prescriptions for asthma therapy at any time in their recorded history, and receiving first prescription of ICS therapy as either extrafine-particle (ciclesonide or hydrofluoroalkane beclomethasone dipropionate [BDP]) or fine-particle ICS (fluticasone propionate or non-extrafine-particle-BDP). Patients were matched (1:1) on relevant demographic and clinical characteristics over 1-year baseline. Primary outcomes were severe exacerbation rates, risk domain asthma control and overall asthma control during the year following first ICS prescription. Secondary outcomes, treatment stability and being prescribed higher versus lower category of short-acting β2 agonists (SABA) dose, were compared over a 1-year outcome period using conditional logistic regression models. Results Following matching, 1399 patients were selected in each treatment cohort (median age: 43 years; males: 34 %). Median (interquartile range) initial ICS doses (fluticasone-equivalents in μg) were 160 (160 − 320) for extrafine-particle versus 500 (250 − 500) for fine-particle ICS (p < 0.001). Following adjustment for residual confounders, matched patients prescribed extrafine-particle ICS had significantly lower rates of exacerbations (adjusted rate ratio [95 % CI], 0.59 [0.47–0.73]), and significantly higher odds of achieving asthma control and treatment stability in the year following initiation than those prescribed fine-particle ICS, and this occurred at lower prescribed doses. Patients prescribed extrafine-particle ICS had lower odds of being prescribed higher doses of SABA (0.50 [0.44–0.57]). Conclusion In this historical, matched study, extrafine-particle ICS was associated with better odds of asthma control than fine-particle ICS in patients prescribed their first ICS therapy in the Netherlands. Of importance, this was reached at significantly lower prescribed dose. Electronic supplementary material The online version of this article (doi:10.1186/s12890-016-0234-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thys van der Molen
- Department of General Practice, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Dirkje S Postma
- Department of Pulmonary Medicine, University of Groningen, University Medical Center, Groningen, The Netherlands
| | | | - Ron M C Herings
- Pharmo Institute for Drugs Outcome Research, Utrecht, The Netherlands
| | - Jetty A Overbeek
- Pharmo Institute for Drugs Outcome Research, Utrecht, The Netherlands
| | | | | | | | - Nicolas Roche
- Groupe Hospitalier Cochin, AP-HP and University Paris Descartes, Paris, France
| | - Theresa Guilbert
- Cincinnati Children's Hospital and Medical Center, Cincinnati, USA
| | - Elliot Israel
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Wim van Aalderen
- Emma's Children Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Simon van Rysewyk
- Observational & Pragmatic Research Institute Pte, Ltd, Singapore, Singapore
| | - David B Price
- Observational & Pragmatic Research Institute Pte, Ltd, Singapore, Singapore. .,Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, AB25 2ZD, Aberdeen, UK.
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Cao AM, Cox MR, Eslick GD. Study design in evidence-based surgery: What is the role of case-control studies? World J Methodol 2016; 6:101-104. [PMID: 27019801 PMCID: PMC4804244 DOI: 10.5662/wjm.v6.i1.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/05/2015] [Accepted: 01/04/2016] [Indexed: 02/07/2023] Open
Abstract
Randomized controlled trials (RCTs) are the gold standard in terms of study design, however, in the surgical setting conducting RCTs can often be unethical or logistically impossible. Case-control studies should become the major study design used in surgical research when RCTs are unable to be conducted and definitely replacing case series which offer little insight into surgical outcomes and disease processes.
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Media Coverage, Journal Press Releases and Editorials Associated with Randomized and Observational Studies in High-Impact Medical Journals: A Cohort Study. PLoS One 2015; 10:e0145294. [PMID: 26701758 PMCID: PMC4689375 DOI: 10.1371/journal.pone.0145294] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 12/02/2015] [Indexed: 11/23/2022] Open
Abstract
Background Publication of clinical research findings in prominent journals influences health beliefs and medical practice, in part by engendering news coverage. Randomized controlled trials (RCTs) should be most influential in guiding clinical practice. We determined whether study design of clinical research published in high-impact journals influences media coverage. Methods and Findings We compared the incidence and amount of media coverage of RCTs with that of observational studies published in the top 7 medical journals between 1 January 2013 and 31 March 2013. We specifically assessed media coverage of the most rigorous RCTs, those with >1000 participants that reported ‘hard’ outcomes. There was no difference between RCTs and observational studies in coverage by major newspapers or news agencies, or in total number of news stories generated (all P>0.63). Large RCTs reporting ‘hard’ outcomes did not generate more news coverage than small RCTs that reported surrogate outcomes and observational studies (all P>0.32). RCTs were more likely than observational studies to attract a journal editorial (70% vs 46%, P = 0.003), but less likely to be the subject of a journal press release (17% vs 50%, P<0.001). Large RCTs that reported ‘hard’ outcomes did not attract an editorial more frequently than other studies (61% vs 58%, P>0.99), nor were they more likely to be the subject of a journal press release (14% vs 38%, P = 0.14). Conclusions The design of clinical studies whose results are published in high-impact medical journals is not associated with the likelihood or amount of ensuing news coverage.
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Cause or Effect? Selective Serotonin Reuptake Inhibitors and Falls in Older Adults: A Systematic Review. Am J Geriatr Psychiatry 2015; 23:1016-28. [PMID: 25586602 PMCID: PMC4442757 DOI: 10.1016/j.jagp.2014.11.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/18/2014] [Accepted: 11/20/2014] [Indexed: 11/23/2022]
Abstract
A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) as potentially inappropriate medications in all older adults based on fall risk. The application of these recommendations, not only to frail nursing home residents, but to all older adults, may lead to changes in health policy or clinical practice with harmful consequences. A systematic review of studies on the association between SSRIs and falls in older adults was conducted to examine the evidence for causation. Twenty-six studies met the inclusion criteria. The majority of studies were observational and suggest an association between SSRIs and falls. The direction of the relationship--causation or effect--cannot be discerned from this type of study. Standardized techniques for determining likely causation were then used to see if there was support for the hypothesis that SSRIs lead to falls. This analysis did not suggest causation was likely. There is no Level 1 evidence that SSRIs cause falls. Therefore, changes in the current treatment guidelines or policies on the use of SSRIs in older adults based on fall risk may not be justified at this time given the lack of an established evidence base. Given its significance to public health, well-designed experimental studies are required to address this question definitively.
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Abstract
BACKGROUND Drug addiction is a chronic, relapsing disease. Primary interventions should aim to reduce first use or to prevent the transition from experimental use to addiction. School is the appropriate setting for preventive interventions. OBJECTIVES To evaluate the effectiveness of universal school-based interventions in reducing drug use compared to usual curricular activities or no intervention. SEARCH METHODS We searched the Cochrane Drugs and Alcohol Group's Trials Register (September 2013), the Cochrane Central Register of Controlled Trials (2013, Issue 9), PubMed (1966 to September 2013), EMBASE (1988 to September 2013) and other databases. We also contacted researchers in the field and checked reference lists of articles. SELECTION CRITERIA Randomised controlled trials (RCT) evaluating school-based interventions designed to prevent illicit drugs use. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We included 51 studies, with 127,146 participants. Programmes were mainly delivered in sixth and seventh grade pupils. Most of the trials were conducted in the USA. Social competence approach versus usual curricula or no intervention Marijuana use at < 12 months follow-up: the results favoured the social competence intervention (risk ratio (RR) 0.90; 95% confidence interval (CI) 0.81 to 1.01, four studies, 9456 participants, moderate quality evidence). Seven studies assessed this outcome (no data for meta-analysis): two showed a positive significant effect of intervention, three showed a non-significant effect, one found a significant effect in favour of the control group and one found a trend in favour of the control group.Marijuana use at 12+ months: the results favoured the social competence intervention (RR 0.86; 95% CI 0.74 to 1.00, one study, 2678 participants, high quality evidence). Seven studies assessed this outcome (no data for meta-analysis): two showed a significant positive effect of intervention, three showed a non-significant effect, one found a significant effect in favour of the control group and one a trend in favour of the control group.Hard drug use at < 12 months: we found no difference (RR 0.69; 95% CI 0.40 to 1.18, one study, 2090 participants, moderate quality evidence). Two studies assessed this outcome (no data for meta-analysis): one showed comparable results for the intervention and control group; one found a statistically non-significant trend in favour of the social competence approach.Hard drug use at 12+ months: we found no difference (mean difference (MD) -0.01; 95% CI -0.06 to 0.04), one study, 1075 participants, high quality evidence). One study with no data for meta-analysis showed comparable results for the intervention and control group.Any drug use at < 12 months: the results favoured social competence interventions (RR 0.27; 95% CI 0.14 to 0.51, two studies, 2512 participants, moderate quality evidence). One study with 1566 participants provided continuous data showing no difference (MD 0.02; 95% CI -0.05 to 0.09, moderate quality evidence). Social influence approach versus usual curricula or no intervention Marijuana use at < 12 months: we found a nearly statistically significant effect in favour of the social influence approach (RR 0.88; 95% CI 0.72 to 1.07, three studies, 10,716 participants, moderate quality evidence). One study with 764 participants provided continuous data showing results that favoured the social influence intervention (MD -0.26; 95% CI -0.48 to -0.04).Marijuana use at 12+ months: we found no difference (RR 0.95; 95% CI 0.81 to 1.13, one study, 5862 participants, moderate quality evidence). One study with 764 participants provided continuous data and showed nearly statistically significant results in favour of the social influence intervention (MD -0.22; 95% CI -0.46 to 0.02). Of the four studies not providing data for meta-analysis a statistically significant protective effect was only found by one study.Hard drug use at 12+ months: one study not providing data for meta-analysis found a significant protective effect of the social influence approach.Any drug use: no studies assessed this outcome. Combined approach versus usual curricula or no intervention Marijuana use at < 12 months: there was a trend in favour of intervention (RR 0.79; 95% CI 0.59 to 1.05, three studies, 8701 participants, moderate quality evidence). One study with 693 participants provided continuous data and showed no difference (MD -1.90; 95% CI -5.83 to 2.03).Marijuana use at 12+ months: the results favoured combined intervention (RR 0.83; 95% CI 0.69 to 0.99, six studies, 26,910 participants, moderate quality evidence). One study with 690 participants provided continuous data and showed no difference (MD -0.80; 95% CI -4.39 to 2.79). Two studies not providing data for meta-analysis did not find a significant effect.Hard drug use at < 12 months: one study with 693 participants provided both dichotomous and continuous data and showed conflicting results: no difference for dichotomous outcomes (RR 0.85; 95% CI 0.63 to 1.14), but results in favour of the combined intervention for the continuous outcome (MD -3.10; 95% CI -5.90 to -0.30). The quality of evidence was high.Hard drug use at 12+ months: we found no difference (RR 0.86; 95% CI 0.39 to 1.90, two studies, 1066 participants, high quality evidence). One study with 690 participants provided continuous data and showed no difference (MD 0.30; 95% CI -1.36 to 1.96). Two studies not providing data for meta-analysis showed a significant effect of treatment.Any drug use at < 12 months: the results favoured combined intervention (RR 0.76; 95% CI 0.64 to 0.89, one study, 6362 participants).Only one study assessed the effect of a knowledge-focused intervention on drug use and found no effect. The types of comparisons and the programmes assessed in the other two groups of studies were very heterogeneous and difficult to synthesise. AUTHORS' CONCLUSIONS School programmes based on a combination of social competence and social influence approaches showed, on average, small but consistent protective effects in preventing drug use, even if some outcomes did not show statistical significance. Some programmes based on the social competence approach also showed protective effects for some outcomes.Since the effects of school-based programmes are small, they should form part of more comprehensive strategies for drug use prevention in order to achieve a population-level impact.
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Affiliation(s)
- Fabrizio Faggiano
- Department of TranslationalMedicine, Università del PiemonteOrientale, Via Solaroli 17,Novara, NO, 28100, Italy.
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Nony P, Kurbatova P, Bajard A, Malik S, Castellan C, Chabaud S, Volpert V, Eymard N, Kassai B, Cornu C. A methodological framework for drug development in rare diseases. Orphanet J Rare Dis 2014; 9:164. [PMID: 25774598 PMCID: PMC4255937 DOI: 10.1186/s13023-014-0164-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 10/14/2014] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Developing orphan drugs is challenging because of their severity and the requisite for effective drugs. The small number of patients does not allow conducting adequately powered randomized controlled trials (RCTs). There is a need to develop high quality, ethically investigated, and appropriately authorized medicines, without subjecting patients to unnecessary trials. AIMS AND OBJECTIVES The main aim is to develop generalizable framework for choosing the best-performing drug/endpoint/design combinations in orphan drug development using an in silico modeling and trial simulation approach. The two main objectives were (i) to provide a global strategy for each disease to identify the most relevant drugs to be evaluated in specific patients during phase III RCTs, (ii) and select the best design for each drug to be used in future RCTs. METHODOLOGICAL APPROACH In silico phase III RCT simulation will be used to find the optimal trial design and was carried out in two steps: (i) statistical analysis of available clinical databases and (ii) integrative modeling that combines mathematical models for diseases with pharmacokinetic-pharmacodynamics models for the selected drug candidates. CONCLUSION There is a need to speed up the process of orphan drug development, develop new methods for translational research and personalized medicine, and contribute to European Medicines Agency guidelines. The approach presented here offers many perspectives in clinical trial conception.
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Quality standards for real-world research. Focus on observational database studies of comparative effectiveness. Ann Am Thorac Soc 2014; 11 Suppl 2:S99-104. [PMID: 24559028 DOI: 10.1513/annalsats.201309-300rm] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Real-world research can use observational or clinical trial designs, in both cases putting emphasis on high external validity, to complement the classical efficacy randomized controlled trials (RCTs) with high internal validity. Real-world research is made necessary by the variety of factors that can play an important a role in modulating effectiveness in real life but are often tightly controlled in RCTs, such as comorbidities and concomitant treatments, adherence, inhalation technique, access to care, strength of doctor-caregiver communication, and socio-economic and other organizational factors. Real-world studies belong to two main categories: pragmatic trials and observational studies, which can be prospective or retrospective. Focusing on comparative database observational studies, the process aimed at ensuring high-quality research can be divided into three parts: preparation of research, analyses and reporting, and discussion of results. Key points include a priori planning of data collection and analyses, identification of appropriate database(s), proper outcomes definition, study registration with commitment to publish, bias minimization through matching and adjustment processes accounting for potential confounders, and sensitivity analyses testing the robustness of results. When these conditions are met, observational database studies can reach a sufficient level of evidence to help create guidelines (i.e., clinical and regulatory decision-making).
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Herrington W, Haynes R, Staplin N, Emberson J, Baigent C, Landray M. Evidence for the prevention and treatment of stroke in dialysis patients. Semin Dial 2014; 28:35-47. [PMID: 25040468 PMCID: PMC4320775 DOI: 10.1111/sdi.12281] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The risks of both ischemic and hemorrhagic stroke are particularly high in dialysis patients of any age and outcomes are poor. It is therefore important to identify strategies that safely minimize stroke risk in this population. Observational studies have been unable to clarify the relative importance of traditional stroke risk factors such as blood pressure and cholesterol in those on dialysis, and are affected by biases that usually make them an inappropriate source of data on which to base therapeutic decisions. Well-conducted randomized trials are not susceptible to such biases and can reliably investigate the causal nature of the association between a potential risk factor and the outcome of interest. However, dialysis patients have been under-represented in the cardiovascular trials which have proven net benefit of commonly used preventative treatments (e.g., antihypertensive treatments, low-dose aspirin, carotid revascularization, and thromboprophylaxis for atrial fibrillation), and there remains uncertainty about safety and efficacy of many of these treatments in this high-risk population. Moreover, the efficacy of renal-specific therapies that might reduce cardiovascular risk, such as modulators of mineral and bone disorder, online hemodiafiltration, and daily (nocturnal) hemodialysis, have not been tested in adequately powered trials. Recent trials have also demonstrated how widespread current practices could be causing stroke. Therefore, it is important that reliable information on the prevention and treatment of stroke (and other cardiovascular disease) in dialysis patients is generated by performing large-scale randomized trials of many current and future treatments.
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Affiliation(s)
- William Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Oxford Kidney Unit, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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Finfer S. Expert consensus: a flawed process for producing guidelines for the management of fluid therapy in the critically ill. Br J Anaesth 2014; 113:735-7. [PMID: 24893783 DOI: 10.1093/bja/aeu141] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- S Finfer
- The George Institute for Global Health and Royal North Shore Hospital, The University of Sydney, St Leonards, NSW 2065, Australia
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Neal B. Dietary Salt Is a Public Health Hazard That Requires Vigorous Attack. Can J Cardiol 2014; 30:502-6. [DOI: 10.1016/j.cjca.2014.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 02/13/2014] [Accepted: 02/13/2014] [Indexed: 11/25/2022] Open
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