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Buta F, Paoletti G, Bragato MC, Giovannini M, Canonica GW, Heffler E. Real-world evidence of allergen immunotherapy. Curr Opin Allergy Clin Immunol 2024:00130832-990000000-00151. [PMID: 39212626 DOI: 10.1097/aci.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
PURPOSE OF REVIEW The full understanding of the long-term effectiveness and safety of allergen immunotherapy (AIT) for allergic respiratory diseases cannot be achieved through randomized controlled trials (RCTs) alone. However, real-world studies designed as registries can complement RCTs. RECENT FINDINGS The significance of registries is highlighted by their potential to reassess contraindications and collect data on adult and pediatric patients with multiple comorbidities who are often excluded from RCTs. SUMMARY AIT is the sole disease-modifying therapeutic approach capable of inducing tolerance and offering a long-term response to allergens. AIT has been shown to play a role in arresting the 'allergic march' in young people, which reduces the risk of developing asthmatic clinical manifestations. Although RCTs are considered the gold standard for evaluating the efficacy and safety of AIT, their duration is usually too short (seldom lasting more than 1 year) to assess the long-term effects of AIT. Several long-term studies show that AIT's effect depends strongly on its use duration.
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Affiliation(s)
- Federica Buta
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, Messina
| | - Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele
| | - Maria Chiara Bragato
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele
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Pérez Montero A, Sanz-Rosa D, Carnés J. Retrospective, Real Life Study on the Effectiveness and Safety of a Depigmented-Polymerized Subcutaneous Vaccine Containing a Mixture of Grasses and Olea europaea. Int Arch Allergy Immunol 2024:1-8. [PMID: 39089230 DOI: 10.1159/000540280] [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: 01/30/2024] [Accepted: 06/21/2024] [Indexed: 08/03/2024] Open
Abstract
INTRODUCTION Allergen immunotherapy is the only modifying treatment of the natural course of respiratory allergic diseases; however, the lack of evidence leads to little inconclusive results. Real life studies are on the rise and are becoming a valuable tool to confirm and complement findings from clinical trials. The objective of this study was to evaluate the effectiveness and safety of a depigmented-polymerized undiluted subcutaneous extract of grass and olive pollen, under routine clinical practice conditions. METHODS This was an observational, retrospective, longitudinal, single-center study on the use of a 2-pollen (grass mix and Olea europaea) undiluted subcutaneous extract over at least 3 consecutive years. Data were collected from 76 patients (n = 44 female; median age: 12.5 years old) diagnosed with allergic rhinoconjunctivitis with/without allergic asthma due to sensitization to both grasses and O. europaea. Primary and secondary effectiveness endpoints were symptom severity, concomitant medication, and immunological profile before and after completing the immunotherapy. A 2-year follow-up of patients' symptoms and medication history after completing the subcutaneous immunotherapy (SCIT) was performed. RESULTS There was a significant improvement of symptoms and medication consumption after 3 years of SCIT treatment, and a significant decrease in specific IgE levels for grasses and O. europaea was observed after finishing the treatment. CONCLUSION Three years treatment of allergic patients using an undiluted mixture of two allergen extracts was shown to be safe and effective for rhinitis and asthma, with efficacy maintained for at least 2 years after finishing SCIT. These results reinforce the importance of real life clinical data in addition to those from clinical trials, helping to individualize allergic treatments.
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Affiliation(s)
- Ana Pérez Montero
- Alergology Hospital Universitario Quirónsalud Madrid, Madrid, Spain
- Department of Medicine, Faculty of Biomedicine and Health, Universidad Europea Madrid, Madrid, Spain
| | - David Sanz-Rosa
- Department of Medicine, Faculty of Biomedicine and Health, Universidad Europea Madrid, Madrid, Spain
| | - Jerónimo Carnés
- R&D Allery and Immunology Unit, LETI Pharma S.L, Madrid, Spain
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Holthuis EI, Heins MJ, van Houdt WJ, Haas RL, Overbeek JA, Olde Hartman TC, Uijen AA, Wee L, van der Graaf WTA, Husson O. Improving Diagnosis and Care for Patients With Sarcoma: Do Real-World General Practitioners Data and Prospective Data Collections Have a Place Next to Clinical Trials? JCO Clin Cancer Inform 2024; 8:e2400054. [PMID: 38950319 DOI: 10.1200/cci.24.00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/16/2024] [Accepted: 05/10/2024] [Indexed: 07/03/2024] Open
Abstract
There has been growing interest in the use of real-world data (RWD) to address clinically and policy-relevant (research) questions that cannot be answered with data from randomized controlled trials (RCTs) alone. This is, for example, the case in rare malignancies such as sarcomas as limited patient numbers pose challenges in conducting RCTs within feasible timeliness, a manageable number of collaborators, and statistical power. This narrative review explores the potential of RWD to generate real-world evidence (RWE) in sarcoma research, elucidating its application across different phases of the patient journey, from prediagnosis to the follow-up/survivorship phase. For instance, examining electronic health records (EHRs) from general practitioners (GPs) enables the exploration of consultation frequency and presenting symptoms in primary care before a sarcoma diagnosis. In addition, alternative study designs that integrate RWD with well-designed observational RCTs may offer relevant information on the effectiveness of clinical treatments. As, especially in cases of ultrarare sarcomas, it can be an extreme challenge to perform well-powered randomized prospective studies. Therefore, it is crucial to support the adaptation of novel study designs. Regarding the follow-up/survivorship phase, examining EHR from primary and secondary care can provide valuable insights into identifying the short- and long-term effects of treatment over an extended follow-up period. The utilization of RWD also comes with several challenges, including issues related to data quality and privacy, as described in this study. Notwithstanding these challenges, this study underscores the potential of RWD to bridge, at least partially, gaps between evidence and practice and holds promise in contributing to the improvement of sarcoma care.
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Affiliation(s)
- Emily I Holthuis
- Medical Oncology Department, NKI-AVL-Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Marianne J Heins
- Netherlands Institute for Health Services Research (Nivel), Utrecht, the Netherlands
| | - Winan J van Houdt
- Surgical Oncology Department, NKI-AVL-Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Rick L Haas
- Department of Radiotherapy, NKI-AVL-Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Jetty A Overbeek
- PHARMO Institute for Drug Outcomes Research, Utrecht, the Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute of Medical Innovation, Nijmegen, the Netherlands
| | - Annemarie A Uijen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute of Medical Innovation, Nijmegen, the Netherlands
| | - Leonard Wee
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, the Netherlands
| | - Winette T A van der Graaf
- Medical Oncology Department, NKI-AVL-Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Olga Husson
- Medical Oncology Department, NKI-AVL-Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
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Gattellari M. Back to the Future: Observational Studies and Anticoagulant Selection for Nonvalvular Atrial Fibrillation. Stroke 2024; 55:1171-1173. [PMID: 38511348 DOI: 10.1161/strokeaha.124.046497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Affiliation(s)
- Melina Gattellari
- Department of Neurology, The Royal Prince Alfred Hospital, Camperdown, Australia
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Schliess F, Affini Dicenzo T, Gaus N, Bourez JM, Stegbauer C, Szecsenyi J, Jacobsen M, Müller-Wieland D, Kulzer B, Heinemann L. The German Fast Track Toward Reimbursement of Digital Health Applications: Opportunities and Challenges for Manufacturers, Healthcare Providers, and People With Diabetes. J Diabetes Sci Technol 2024; 18:470-476. [PMID: 36059268 PMCID: PMC10973846 DOI: 10.1177/19322968221121660] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Digital health applications (DiGA) supporting the management of diabetes are among the most commonly available digital health technologies. However, transparent quality assurance of DiGA and clinical proof of a positive healthcare effect is often missing, which creates skepticism of some stakeholders regarding the usage and reimbursement of these applications. METHODS This article reviews the recently established fast-track integration of DiGA in the German reimbursement market, with emphasis on the current impact for manufacturers, healthcare providers, and people with diabetes. The German DiGA fast track is contextualised with corresponding initiatives in Europe. RESULTS The option of a provisional prescription and reimbursement of DiGA while proving a positive healthcare effect in parallel may expedite the adoption of DiGA in Germany and beyond. However, hurdles for a permanent prescription and reimbursement of DiGA are high and only one of 12 that have achieved this status specifically addresses people with diabetes. CONCLUSION The DiGA fast track needs to be further enhanced to cope with remaining skepticism and contribute even more to a value-based diabetes care.
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Affiliation(s)
| | | | | | | | - Constance Stegbauer
- AQUA Institute for Applied Quality Improvement and Research in Healthcare GmbH, Göttingen, Germany
| | - Joachim Szecsenyi
- AQUA Institute for Applied Quality Improvement and Research in Healthcare GmbH, Göttingen, Germany
| | - Malte Jacobsen
- Department of Internal Medicine I, RWTH Aachen University Hospital, Aachen, Germany
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, RWTH Aachen University Hospital, Aachen, Germany
| | | | - Lutz Heinemann
- Profil Institut für Stoffwechselforschung GmbH, Neuss, Germany
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6
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Bishara S. Adapting power calculations to include a superiority margin: what are the implications? Biochem Med (Zagreb) 2024; 34:010101. [PMID: 38361735 PMCID: PMC10864028 DOI: 10.11613/bm.2024.010101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 11/16/2023] [Indexed: 02/17/2024] Open
Abstract
This paper examines the application of super-superiority margins in study power calculations. Unlike traditional power calculations, which primarily aim to reject the null hypothesis by any margin, a super-superiority margin establishes a clinically significant threshold. Despite potential benefits, this approach, akin to a non-inferiority calculation but in an opposing direction, is rarely used. Implementing a super-superiority margin separates the notion of the likely difference between two groups (the effect size) from the minimum clinically significant difference, without which inconsistent positions could be held. However, these are often used interchangeably. In an audit of 30 recent randomized controlled trial power calculations, four studies utilized the minimal acceptable difference, and nine utilized the expected difference. In the other studies, this was unclarified. In the post hoc scenario, this approach can shed light on the value of undertaking further studies, which is not apparent from the standard power calculation. The acceptance and rejection of the alternate hypothesis for super-superiority, non-inferiority, equivalence, and standard superiority studies have been compared. When a fixed minimal acceptable difference is applied, a study result will be in one of seven logical positions with regards to the simultaneous application of these hypotheses. The trend for increased trial size and the mirror approach of non-inferiority studies implies that newer interventions may be becoming less effective. Powering for superiority could counter this and ensure that a pre-trial evaluation of clinical significance has taken place, which is necessary to confirm that interventions are beneficial.
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Affiliation(s)
- Samuel Bishara
- Division of surgery, West Middlesex Hospital, Chelsea and Westminster NHS Trust, United Kingdom
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Tjerkaski J, Jernberg T, Szummer K. Balancing the risks of bleeding and ischaemia in myocardial infarction patients at high bleeding risk. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:770-771. [PMID: 37740444 PMCID: PMC10719447 DOI: 10.1093/ehjcvp/pvad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 09/24/2023]
Affiliation(s)
- J Tjerkaski
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm 182 88, Sweden
| | - T Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm 182 88, Sweden
| | - K Szummer
- Section of Cardiology, Department of Medicine, Karolinska Institutet, Huddinge, Stockholm 171 77, Sweden
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Shapiro L, Scherger S, Franco-Paredes C, Gharamti A, Henao-Martinez AF. Anakinra authorized to treat severe coronavirus disease 2019; Sepsis breakthrough or time to reflect? Front Microbiol 2023; 14:1250483. [PMID: 37928695 PMCID: PMC10620707 DOI: 10.3389/fmicb.2023.1250483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/26/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction The European Medicines Agency (EMA) and the United States Food and Drug Administration (FDA) announced conditions for using recombinant human interleukin-1 receptor antagonist (rhIL-1ra) to treat hospitalized patients with Coronavirus disease 2019 (COVID-19) and risk for progression. These decisions followed publication of the suPAR-guided Anakinra treatment for Validation of the risk and early Management OF seveRE respiratory failure by COVID-19 (SAVE- MORE) phase 3 clinical trial that yielded positive results. Methods We conducted a literature review and theoretical analysis of IL-1 blockade as a therapy to treat COVID-19. Using a stepwise analysis, we assessed clinical applicability of the SAVE-MORE results and evaluated conceptual support for interleukin-1 suppression as a suitable approach to COVID-19 treatment. This therapeutic approach was then examined as an example of inflammation-suppressing measures used to treat sepsis. Results Anakinra use as a COVID-19 therapy seems to rely on a view of pathogenesis that incorrectly reflects human disease. Since COVID-19 is an example of sepsis, COVID-19 benefit due to anti-inflammatory therapy contradicts an extensive history of unsuccessful clinical study. Repurposing rhIL-1ra to treat COVID-19 appears to exemplify a cycle followed by inflammation-suppressing sepsis treatments. A landscape of treatment failures is interrupted by a successful clinical trial. However, subsequent confirmatory study fails to replicate the positive data. Discussion We suggest further experimentation is not a promising pathway to discover game-changing sepsis therapies. A different kind of approach may be necessary.
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Affiliation(s)
- Leland Shapiro
- Division of Infectious Diseases, Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Sias Scherger
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Carlos Franco-Paredes
- Hospital Infantil de México, Federico Gómez, México City, México
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Collins, CO, United States
| | - Amal Gharamti
- Department of Internal Medicine, Yale University, Waterbury, CT, United States
| | - Andrés F. Henao-Martinez
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Hsu YC, Tseng CH, Kao JH. Safety considerations for withdrawal of nucleos(t)ide analogues in patients with chronic hepatitis B: First, do no harm. Clin Mol Hepatol 2023; 29:869-890. [PMID: 36916171 PMCID: PMC10577354 DOI: 10.3350/cmh.2022.0420] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 02/19/2023] [Accepted: 03/13/2023] [Indexed: 03/16/2023] Open
Abstract
Nucleos(t)ide analogues (NA) are widely used to treat hepatitis B virus (HBV) infection, but they cannot eradicate the virus and treatment duration can be lifelong if the endpoint is set at seroclearance of the hepatitis B surface antigen (HBsAg). As an alternative strategy, finite NA therapy without the prerequisite of HBsAg seroclearance has been proposed to allow treatment cessation in patients with sustained undetectable HBV viremia for two to three years. However, reactivation of viral replication almost always follows NA withdrawal. Whereas HBV reactivation might facilitate HBsAg seroclearance in some, it could lead to serious acute flare-ups in a certain proportion of patients. Occurrence and consequences of NA withdrawal flares are complicated with various factors involving the virus, host, and treatment. Accurate risk prediction for severe flares following NA cessation is essential to ensure patient safety. The risks of life-threatening flares in patients who discontinued NA according to the stopping rules of current guidelines or local reimbursement policies have recently been quantitatively estimated in large-scale studies, which also provided empirical evidence to help identify vulnerable patients at risk of devastating outcomes. Moreover, risk predictors were further explored and validated to hopefully aid in patient selection and management. In this narrative review with a focus on patient safety, we summarize and discuss current literature on the incidence of severe flares following NA cessation, risk stratification for candidate selection, rules of posttreatment monitoring, and indications for treatment resumption. We also share our thoughts on the limitations of existing knowledge and suggestions for future research.
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Affiliation(s)
- Yao-Chun Hsu
- Department of Medical Research, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Internal Medicine, Fu-Jen Catholic University Hospital, New Taipei, Taiwan
- Institute of Biomedical Informatics, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Hao Tseng
- School of Medicine College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Gastroenterology and Hepatology, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Jia-Horng Kao
- Department of Internal Medicine and Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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Ntanasis-Stathopoulos I, Malandrakis P, Fotiou D, Migkou M, Theodorakakou F, Roussou M, Eleutherakis-Papaiakovou E, Spiliopoulou V, Kastritis E, Terpos E, Dimopoulos MA, Gavriatopoulou M. Real-World Effectiveness and Safety of Belantamab Mafodotin Monotherapy in Triple-Class Refractory Multiple Myeloma. Int J Mol Sci 2023; 24:11829. [PMID: 37511588 PMCID: PMC10380484 DOI: 10.3390/ijms241411829] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
B-cell maturation antigen (BCMA) is a promising therapeutic target for multiple myeloma (MM). The aim of this study was to assess the effectiveness and tolerability of monotherapy with the conjugated anti-BCMA monoclonal antibody belantamab mafodotin in triple-class refractory patients with MM in real-world practice. Patients refractory to at least one proteasome inhibitor, one immunomodulatory drug, and one anti-CD38 monoclonal antibody received belantamab mafodotin at 2.5 mg/kg intravenously every 3 weeks. Overall, 27 patients with a median age of 65 years (range 41-81) were included. Of these, 52% were male and the median number of prior lines of treatment was 5 (4-10). The overall response rate (partial response or better) was 52%, whereas the disease control rate (stable disease or better) was 70%. The median progression-free survival (PFS) was 2 months (95%CI: 0-7), whereas the median PFS among the responders was 12 months (95%CI: 6-18). Regarding the toxicity profile, the most common toxicity was eye toxicity, in 44% of the patients. Keratopathy grade 2-3 was reported in 33.3% of the patients. In conclusion, belantamab mafodotin showed a safety and efficacy profile consistent with the results of the registrational study. Importantly, heavily pretreated patients who responded to treatment derived a substantial survival benefit.
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Affiliation(s)
- Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Panagiotis Malandrakis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Maria Roussou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | | | - Vassiliki Spiliopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Meletios-Athanasios Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 157 72 Athens, Greece
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Saesen R, Van Hemelrijck M, Bogaerts J, Booth CM, Cornelissen JJ, Dekker A, Eisenhauer EA, Freitas A, Gronchi A, Hernán MA, Hulstaert F, Ost P, Szturz P, Verkooijen HM, Weller M, Wilson R, Lacombe D, van der Graaf WT. Defining the role of real-world data in cancer clinical research: The position of the European Organisation for Research and Treatment of Cancer. Eur J Cancer 2023; 186:52-61. [PMID: 37030077 DOI: 10.1016/j.ejca.2023.03.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 04/07/2023]
Abstract
The emergence of the precision medicine paradigm in oncology has led to increasing interest in the integration of real-world data (RWD) into cancer clinical research. As sources of real-world evidence (RWE), such data could potentially help address the uncertainties that surround the adoption of novel anticancer therapies into the clinic following their investigation in clinical trials. At present, RWE-generating studies which investigate antitumour interventions seem to primarily focus on collecting and analysing observational RWD, typically forgoing the use of randomisation despite its methodological benefits. This is appropriate in situations where randomised controlled trials (RCTs) are not feasible and non-randomised RWD analyses can offer valuable insights. Nevertheless, depending on how they are designed, RCTs have the potential to produce strong and actionable RWE themselves. The choice of which methodology to employ for RWD studies should be guided by the nature of the research question they are intended to answer. Here, we attempt to define some of the questions that do not necessarily require the conduct of RCTs. Moreover, we outline the strategy of the European Organisation for Research and Treatment of Cancer (EORTC) to contribute to the generation of robust and high-quality RWE by prioritising the execution of pragmatic trials and studies set up according to the trials-within-cohorts approach. If treatment allocation cannot be left up to random chance due to practical or ethical concerns, the EORTC will consider undertaking observational RWD research based on the target trial principle. New EORTC-sponsored RCTs may also feature concurrent prospective cohorts composed of off-trial patients.
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Tagliamento M, Gennari A, Lambertini M, Salazar R, Harbeck N, Del Mastro L, Aguilar-Company J, Bower M, Sharkey R, Dalla Pria A, Plaja A, Jackson A, Handford J, Sita-Lumsden A, Martinez-Vila C, Matas M, Miguel Rodriguez A, Vincenzi B, Tonini G, Bertuzzi A, Brunet J, Pedrazzoli P, D'Avanzo F, Biello F, Sinclair A, Lee AJ, Rossi S, Rizzo G, Mirallas O, Pimentel I, Iglesias M, Sanchez de Torre A, Guida A, Berardi R, Zambelli A, Tondini C, Filetti M, Mazzoni F, Mukherjee U, Diamantis N, Parisi A, Aujayeb A, Prat A, Libertini M, Grisanti S, Rossi M, Zoratto F, Generali D, Saura C, Lyman GH, Kuderer NM, Pinato DJ, Cortellini A. Pandemic Phase-Adjusted Analysis of COVID-19 Outcomes Reveals Reduced Intrinsic Vulnerability and Substantial Vaccine Protection From Severe Acute Respiratory Syndrome Coronavirus 2 in Patients With Breast Cancer. J Clin Oncol 2023; 41:2800-2814. [PMID: 36720089 PMCID: PMC10414724 DOI: 10.1200/jco.22.01667] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/07/2022] [Accepted: 12/12/2022] [Indexed: 02/02/2023] Open
Abstract
PURPOSE Although representing the majority of newly diagnosed cancers, patients with breast cancer appear less vulnerable to COVID-19 mortality compared with other malignancies. In the absence of patients on active cancer therapy included in vaccination trials, a contemporary real-world evaluation of outcomes during the various pandemic phases, as well as of the impact of vaccination, is needed to better inform clinical practice. METHODS We compared COVID-19 morbidity and mortality among patients with breast cancer across prevaccination (February 27, 2020-November 30, 2020), Alpha-Delta (December 1, 2020-December 14, 2021), and Omicron (December 15, 2021-January 31, 2022) phases using OnCovid registry participants (ClinicalTrials.gov identifier: NCT04393974). Twenty-eight-day case fatality rate (CFR28) and COVID-19 severity were compared in unvaccinated versus double-dosed/boosted patients (vaccinated) with inverse probability of treatment weighting models adjusted for country of origin, age, number of comorbidities, tumor stage, and receipt of systemic anticancer therapy within 1 month of COVID-19 diagnosis. RESULTS By the data lock of February 4, 2022, the registry counted 613 eligible patients with breast cancer: 60.1% (n = 312) hormone receptor-positive, 25.2% (n = 131) human epidermal growth factor receptor 2-positive, and 14.6% (n = 76) triple-negative. The majority (61%; n = 374) had localized/locally advanced disease. Median age was 62 years (interquartile range, 51-74 years). A total of 193 patients (31.5%) presented ≥ 2 comorbidities and 69% (n = 330) were never smokers. In total, 392 (63.9%), 164 (26.8%), and 57 (9.3%) were diagnosed during the prevaccination, Alpha-Delta, and Omicron phases, respectively. Analysis of CFR28 demonstrates comparable estimates of mortality across the three pandemic phases (13.9%, 12.2%, 5.3%, respectively; P = .182). Nevertheless, a significant improvement in outcome measures of COVID-19 severity across the three pandemic time periods was observed. Importantly, when reported separately, unvaccinated patients from the Alpha-Delta and Omicron phases achieved comparable outcomes to those from the prevaccination phase. Of 566 patients eligible for the vaccination analysis, 72 (12.7%) were fully vaccinated and 494 (87.3%) were unvaccinated. We confirmed with inverse probability of treatment weighting multivariable analysis and following a clustered robust correction for participating center that vaccinated patients achieved improved CFR28 (odds ratio [OR], 0.19; 95% CI, 0.09 to 0.40), hospitalization (OR, 0.28; 95% CI, 0.11 to 0.69), COVID-19 complications (OR, 0.16; 95% CI, 0.06 to 0.45), and reduced requirement of COVID-19-specific therapy (OR, 0.24; 95% CI, 0.09 to 0.63) and oxygen therapy (OR, 0.24; 95% CI, 0.09 to 0.67) compared with unvaccinated controls. CONCLUSION Our findings highlight a consistent reduction of COVID-19 severity in patients with breast cancer during the Omicron outbreak in Europe. We also demonstrate that even in this population, a complete severe acute respiratory syndrome coronavirus 2 vaccination course is a strong determinant of improved morbidity and mortality from COVID-19.
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Affiliation(s)
- Marco Tagliamento
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Alessandra Gennari
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
- Medical Oncology Department, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Ramon Salazar
- Department of Medical Oncology, ICO L'Hospitalet, Oncobell Program (IDIBELL), CIBERONC, Hospitalet de Llobregat, Barcelona, Spain
| | - Nadia Harbeck
- Department of Gynecology and Obstetrics, Breast Center and Gynecological Cancer Center and CCC Munich, University Hospital Munich, Munich, Germany
| | - Lucia Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
- Medical Oncology Department, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Juan Aguilar-Company
- Medical Oncology, Vall d'Hebron University Hospital and Institute of Oncology (VHIO), Barcelona, Spain
- Infectious Diseases, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mark Bower
- Department of Oncology and National Centre for HIV Malignancy, Chelsea and Westminster Hospital, London, United Kingdom
| | - Rachel Sharkey
- Department of Oncology and National Centre for HIV Malignancy, Chelsea and Westminster Hospital, London, United Kingdom
| | - Alessia Dalla Pria
- Department of Oncology and National Centre for HIV Malignancy, Chelsea and Westminster Hospital, London, United Kingdom
| | - Andrea Plaja
- Medical Oncology Department, B-ARGO Group, IGTP, Catalan Institute of Oncology-Badalona, Badalona, Spain
| | | | - Jasmine Handford
- Translational Oncology and Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Ailsa Sita-Lumsden
- Medical Oncology, Guy's and St Thomas' NHS Foundation Trust (GSTT), London, United Kingdom
| | | | | | | | - Bruno Vincenzi
- Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Giuseppe Tonini
- Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Alexia Bertuzzi
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Joan Brunet
- Department of Medical Oncology, Catalan Institute of Oncology, University Hospital Josep Trueta, Girona, Spain
| | - Paolo Pedrazzoli
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Francesca D'Avanzo
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Federica Biello
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Alasdair Sinclair
- Cancer Division, University College London Hospitals, London, United Kingdom
| | - Alvin J.X. Lee
- Cancer Division, University College London Hospitals, London, United Kingdom
| | - Sabrina Rossi
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Gianpiero Rizzo
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Oriol Mirallas
- Medical Oncology, Vall d'Hebron University Hospital and Institute of Oncology (VHIO), Barcelona, Spain
| | - Isabel Pimentel
- Medical Oncology, Vall d'Hebron University Hospital and Institute of Oncology (VHIO), Barcelona, Spain
| | | | | | - Annalisa Guida
- Department of Oncology, Azienda Ospedaliera Santa Maria, Terni, Italy
| | - Rossana Berardi
- Medical Oncology, AOU Ospedali Riuniti, Polytechnic University of the Marche Region, Ancona, Italy
| | | | - Carlo Tondini
- Oncology Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | | | - Uma Mukherjee
- Medical Oncology, Barts Health NHS Trust, London, United Kingdom
| | | | - Alessandro Parisi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, United Kingdom
| | - Aleix Prat
- Department of Medical Oncology, Hospital Clinic, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, Barcelona, Spain
| | - Michela Libertini
- Medical Oncology Unit, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | | | - Maura Rossi
- Oncology Unit, Azienda Ospedaliera “SS Antonio e Biagio e Cesare Arrigo,” Alessandria, Italy
| | | | - Daniele Generali
- Multidisciplinary Breast Pathology and Translational Research Unit, ASST Cremona, Cremona, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Cristina Saura
- Medical Oncology, Vall d'Hebron University Hospital and Institute of Oncology (VHIO), IOB-Quiron, UVic-UCC, Barcelona, Spain
| | - Gary H. Lyman
- Public Health Sciences Division and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
- Divisions of Public Health Science and Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA
| | | | - David J. Pinato
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Alessio Cortellini
- Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Mutsaers A, Zhang TW, Louie A, Rodrigues G, Palma D, Qu M. Stereotactic or Conventional Radiation for Early-Stage Non-small Cell Lung Cancer: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e38198. [PMID: 37252503 PMCID: PMC10224746 DOI: 10.7759/cureus.38198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 05/31/2023] Open
Abstract
Stereotactic ablative radiotherapy (SABR) has been increasingly used for the treatment of inoperable early-stage non-small cell lung cancer (NSCLC). It has been shown to provide promising local control (LC) and toxicity in prospective trials. However, randomized trials have shown conflicting results in terms of whether SABR confers an overall survival (OS) advantage compared to conventionally fractionated radiotherapy (CFRT). A systematic review of Medline and Embase (inception to December 2020) was performed on early-stage NSCLC patients randomized to SABR versus CFRT. Two independent reviewers screened titles, abstracts, and manuscripts. A random-effects model was used to estimate treatment effects. Toxicity outcomes were compared by the Cochran-Mantel-Haenszel test. Individual patient data were digitally approximated and pooled as secondary analysis. The literature search identified 1494 studies, and 16 studies were included for full-text review. Two randomized trials were identified, including a total of 203 patients, of which 115 (57%) received SABR, and 88 (43%) received CFRT. The weighted mean age was 74 years and 48% of patients were male. Most patients had T1 cancers (67%). Stereotactic ablative radiotherapy was not associated with a significant improvement in OS (hazard ratio: 0.84; 95% confidence interval (CI) 0.34-2.08, p=0.71). There was no significant difference in LC between SABR and CFRT (relative risk: 0.59; CI 0.28-1.23, p=0.16). Of the commonly reported adverse events, one grade 4 toxicity of dyspnea was reported for SABR, while all others i.e., grade 3 or higher toxicities were similar. Stereotactic ablative radiotherapy demonstrated less esophagitis, dyspnea, and skin reaction of any grade. Despite widespread adoption and extensive single-arm prospective and retrospective studies suggesting its benefit, this systematic review and meta-analysis of randomized trials fail to confirm improvements in LC, OS, and toxicity profile of SABR over CFRT in early NSCLC. This small study is likely underpowered to detect clinically significant differences.
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Affiliation(s)
- Adam Mutsaers
- Radiation Oncology, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, CAN
| | | | - Alexander Louie
- Radiation Oncology, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, CAN
| | - George Rodrigues
- Radiation Oncology, Victoria Hospital, London Health Sciences Centre, London, CAN
- Medicine & Dentistry, Western University, London, CAN
| | - David Palma
- Radiation Oncology, Victoria Hospital, London Health Sciences Centre, London, CAN
| | - Melody Qu
- Radiation Oncology, Victoria Hospital, London Health Sciences Centre, London, CAN
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Treating COVID-19: Targeting the Host Response, Not the Virus. Life (Basel) 2023; 13:life13030712. [PMID: 36983871 PMCID: PMC10054780 DOI: 10.3390/life13030712] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/19/2023] [Accepted: 01/31/2023] [Indexed: 03/09/2023] Open
Abstract
In low- and middle-income countries (LMICs), inexpensive generic drugs like statins, ACE inhibitors, and ARBs, especially if used in combination, might be the only practical way to save the lives of patients with severe COVID-19. These drugs will already be available in all countries on the first pandemic day. Because they target the host response to infection instead of the virus, they could be used to save lives during any pandemic. Observational studies show that inpatient statin treatment reduces 28–30-day mortality but randomized controlled trials have failed to show this benefit. Combination treatment has been tested for antivirals and dexamethasone but, with the exception of one observational study in Belgium, not for inexpensive generic drugs. Future pandemic research must include testing combination generic drug treatments that could be used in LMICs.
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15
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Shimoyama R, Imamura Y, Uryu K, Mase T, Fujimura Y, Hayashi M, Ohtaki M, Ohtani K, Shinozaki N, Minami H. Real-World Outcomes of Systemic Therapy in Japanese Patients with Cancer (Tokushukai REAl-World Data Project: TREAD): Study Protocol for a Nationwide Cohort Study. Healthcare (Basel) 2022; 10:healthcare10112146. [PMID: 36360487 PMCID: PMC9690553 DOI: 10.3390/healthcare10112146] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/22/2022] [Accepted: 10/24/2022] [Indexed: 11/30/2022] Open
Abstract
Cohort studies using large-scale databases have become increasingly important in recent years. The Tokushukai Medical Group is a leading medical group in Japan that includes 71 general hospitals nationwide from Hokkaido to Okinawa, with a total of 18,000 beds, and a unified electronic medical record system. This retrospective cohort study aims to evaluate the real-world outcomes of systemic therapy for Japanese patients with cancer using this merit of scale. All adult patients with cancer who received systemic therapy using a centrally registered chemotherapy protocol system at 46 hospitals from April 2010 to March 2020 will be identified (~48,850 patients). Key exclusion criteria include active double cancer and inadequate data extraction. Data will be obtained through electronic medical records, diagnosis procedure combination data, medical prescription data, and the national cancer registration system that includes sociodemographic variables, diagnostic and laboratory tests, concomitant drug prescriptions, cost, and overall survival. Kaplan–Meier estimates will be calculated for time-to-event analyses. Stratified/conventional Cox proportional hazards regression analyses will be conducted to examine the relationships between overall survival and related factors. Our findings provide important insights for future research directions, policy initiatives, medical guidelines, and clinical decision-making.
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Affiliation(s)
- Rai Shimoyama
- Department of General Surgery, Shonankamakura General Hospital, Kamakura 247-8533, Japan
| | - Yoshinori Imamura
- Department of Medical Oncology and Hematology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
- Correspondence: ; Tel.: +81-78-382-5820
| | - Kiyoaki Uryu
- Department of Medical Oncology, Yao Tokushukai General Hospital, Yao 581-0011, Japan
| | - Takahiro Mase
- Department of Breast Surgery, Ogaki Tokushukai Hospital, Ogaki 503-0015, Japan
| | | | - Maki Hayashi
- Mirai Iryo Research Center Inc., Tokyo 102-0083, Japan
| | - Megu Ohtaki
- deCult Co., Ltd., Hatsukaichi 739-0413, Japan
| | | | - Nobuaki Shinozaki
- Department of General Surgery, Shonankamakura General Hospital, Kamakura 247-8533, Japan
- General Incorporated Association Tokushukai, Tokyo 102-0074, Japan
| | - Hironobu Minami
- Department of Medical Oncology and Hematology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
- Cancer Center, Kobe University Hospital, Kobe 650-0017, Japan
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16
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Eriksson JW, Eliasson B, Bennet L, Sundström J. Registry-based randomised clinical trials: a remedy for evidence-based diabetes care? Diabetologia 2022; 65:1575-1586. [PMID: 35902386 PMCID: PMC9334551 DOI: 10.1007/s00125-022-05762-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
This narrative review describes a new approach to navigation in a challenging landscape of clinical drug development in diabetes. Successful outcome studies in recent years have led to new indications and guidelines in type 2 diabetes, yet the number of clinical trials in diabetes is now declining. This is due to many environmental factors acting in concert, including the prioritisation of funding for other diseases, high costs of large randomised clinical trials, increase in regulatory requirements and limited entry of novel candidate drugs. There is a need for novel and cost-effective paradigms of clinical development to meet these and other challenges. The concept of registry-based randomised clinical trials (RRCTs) is an attractive option. In this review we focus on type 2 diabetes and the prevention of cardiovascular and microvascular comorbidities and mortality, using the Swedish SMARTEST trial as an example of an RRCT. We also give some examples from other disease areas. The RRCT concept is a novel, cost-effective and scientifically sound approach for conducting large-scale diabetes trials in a real-world setting.
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Affiliation(s)
- Jan W Eriksson
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden.
| | - Björn Eliasson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Swedish National Diabetes Register, Västra Götalandsregionen, Gothenburg, Sweden
| | - Louise Bennet
- Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden
- Clinical Trials Unit, Skåne University Hospital in Lund, Lund, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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17
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Torbahn G, Brauchmann J, Axon E, Clare K, Metzendorf MI, Wiegand S, Pratt JS, Ells LJ. Surgery for the treatment of obesity in children and adolescents. Cochrane Database Syst Rev 2022; 9:CD011740. [PMID: 36074911 PMCID: PMC9454261 DOI: 10.1002/14651858.cd011740.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Child and adolescent overweight and obesity have increased globally and are associated with significant short- and long-term health consequences. OBJECTIVES To assess the effects of surgery for treating obesity in childhood and adolescence. SEARCH METHODS For this update, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Latin American and Caribbean Health Science Information database (LILACS), World Health Organization International Clinical Trials Registry Platform (ICTRP)and ClinicalTrials.gov on 20 August 2021 (date of the last search for all databases). We did not apply language restrictions. We checked references of identified studies and systematic reviews. SELECTION CRITERIA We selected randomised controlled trials (RCTs) of surgical interventions for treating obesity in children and adolescents (age < 18 years) with a minimum of six months of follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or which included participants with a secondary or syndromic cause of obesity, or who were pregnant. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias using the Cochrane Risk of Bias 2.0 tool. Where necessary, we contacted authors for additional information. MAIN RESULTS With this update, we did not find any new RCTs. Therefore, this updated review still includes a single RCT (a total of 50 participants, 25 in both the intervention and comparator groups). The intervention focused on laparoscopic adjustable gastric banding surgery, which was compared to a control group receiving a multi-component lifestyle programme. The participating population consisted of Australian adolescents (a higher proportion of girls than boys) aged 14 to 18 years, with a mean age of 16.5 and 16.6 years in the gastric banding and lifestyle groups, respectively. The trial was conducted in a private hospital, receiving funding from the gastric banding manufacturer. For most of the outcomes, we identified a high risk of bias, mainly due to bias due to missing outcome data. Laparoscopic gastric banding surgery may reduce BMI by a mean difference (MD) of -11.40 kg/m2 (95% CI -13.22 to -9.58) and weight by -31.60 kg (95% CI -36.66 to -26.54) compared to a multi-component lifestyle programme at two years follow-up. The evidence is very uncertain due to serious imprecision and a high risk of bias. Adverse events were reported in 12/25 (48%) participants in the intervention group compared to 11/25 (44%) in the control group. A total of 28% of the adolescents undergoing gastric banding required revisional surgery. The evidence is very uncertain due to serious imprecision and a high risk of bias. At two years of follow-up, laparoscopic gastric banding surgery may increase health-related quality of life in the physical functioning scores by an MD of 16.30 (95% CI 4.90 to 27.70) and change in health scores by an MD of 0.82 (95% CI 0.18 to 1.46) compared to the lifestyle group. The evidence is very uncertain due to serious imprecision and a high risk of bias. No data were reported for all-cause mortality, behaviour change, participants' views of the intervention and socioeconomic effects. Finally, we have identified three ongoing RCTs that are evaluating the efficacy and safety of metabolic and bariatric surgery in children and adolescents. AUTHORS' CONCLUSIONS Laparoscopic gastric banding led to greater body weight loss compared to a multi-component lifestyle program in one small study with 50 participants. These results have very limited application, primarily due to more recent recommendations derived from observation studies to avoid the use of banding in youth due to long-term reoperation rates. This systematic review update still highlights the lack of RCTs in this field. The authors are concerned that there may be ethical barriers to RTCs in this field, despite the lack of other effective therapies for severe obesity in children and adolescents and the significant morbidity and premature mortality caused by childhood obesity. Nevertheless, future studies, whether pre-registered and planned non-randomised or pragmatic randomised trials, should assess the impact of the surgical procedure and post-operative care to minimise adverse events, including the need for post-operative adjustments and revisional surgery. Long-term follow-up is also critical to comprehensively assess the impact of surgery as participants enter adulthood.
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Affiliation(s)
- Gabriel Torbahn
- Department of Pediatrics, Paracelsus Medical University, Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität Nürnberg, Nuremberg, Germany
- Department of Pediatrics, Paracelsus Medical University, Salzburg, Austria
- Department of Pediatrics, Obesity Research Unit, Paracelsus Medical University, Salzburg, Austria
| | - Jana Brauchmann
- Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Emma Axon
- Cochrane Skin, Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Susanna Wiegand
- Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Janey Sa Pratt
- Department of Pediatric Surgery, Stanford University, Standford, CA, USA
| | - Louisa J Ells
- School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, UK
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Schulz R, Langen G, Prill R, Cassel M, Weissgerber TL. Reporting and transparent research practices in sports medicine and orthopaedic clinical trials: a meta-research study. BMJ Open 2022; 12:e059347. [PMID: 35940834 PMCID: PMC9364413 DOI: 10.1136/bmjopen-2021-059347] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Transparent reporting of clinical trials is essential to assess the risk of bias and translate research findings into clinical practice. While existing studies have shown that deficiencies are common, detailed empirical and field-specific data are scarce. Therefore, this study aimed to examine current clinical trial reporting and transparent research practices in sports medicine and orthopaedics. SETTING Exploratory meta-research study on reporting quality and transparent research practices in orthopaedics and sports medicine clinical trials. PARTICIPANTS The sample included clinical trials published in the top 25% of sports medicine and orthopaedics journals over 9 months. PRIMARY AND SECONDARY OUTCOME MEASURES Two independent reviewers assessed pre-registration, open data and criteria related to scientific rigour, like randomisation, blinding, and sample size calculations, as well as the study sample, and data analysis. RESULTS The sample included 163 clinical trials from 27 journals. While the majority of trials mentioned rigour criteria, essential details were often missing. Sixty per cent (95% confidence interval (CI) 53% to 68%) of trials reported sample size calculations, but only 32% (95% CI 25% to 39%) justified the expected effect size. Few trials indicated the blinding status of all main stakeholders (4%; 95% CI 1% to 7%). Only 18% (95% CI 12% to 24%) included information on randomisation type, method and concealed allocation. Most trials reported participants' sex/gender (95%; 95% CI 92% to 98%) and information on inclusion and exclusion criteria (78%; 95% CI 72% to 84%). Only 20% (95% CI 14% to 26%) of trials were pre-registered. No trials deposited data in open repositories. CONCLUSIONS These results will aid the sports medicine and orthopaedics community in developing tailored interventions to improve reporting. While authors typically mention blinding, randomisation and other factors, essential details are often missing. Greater acceptance of open science practices, like pre-registration and open data, is needed. As these practices have been widely encouraged, we discuss systemic interventions that may improve clinical trial reporting.
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Affiliation(s)
- Robert Schulz
- BIH QUEST Center for Responsible Research, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Sport and Health Sciences, University of Potsdam, Potsdam, Brandenburg, Germany
| | - Georg Langen
- Department of Strength, Power and Tactical Sports, Institute for Applied Training Science, Leipzig, Germany
| | - Robert Prill
- Center of Orthopaedics and Traumatology, Brandenburg Medical School Theodor Fontane, Neuruppin, Brandenburg, Germany
| | - Michael Cassel
- Department of Sport and Health Sciences, University of Potsdam, Potsdam, Brandenburg, Germany
| | - Tracey L Weissgerber
- BIH QUEST Center for Responsible Research, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
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19
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Matthews AA, Dahabreh IJ, Fröbert O, Lindahl B, James S, Feychting M, Jernberg T, Berglund A, Hernán MA. Benchmarking Observational Analyses Before Using Them to Address Questions Trials Do Not Answer: An Application to Coronary Thrombus Aspiration. Am J Epidemiol 2022; 191:1652-1665. [PMID: 35641151 PMCID: PMC9437817 DOI: 10.1093/aje/kwac098] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/31/2022] [Accepted: 05/24/2022] [Indexed: 01/29/2023] Open
Abstract
To increase confidence in the use of observational analyses when addressing effectiveness questions beyond those addressed by randomized trials, one can first benchmark the observational analyses against existing trial results. We used Swedish registry data to emulate a target trial similar to the Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia (TASTE) randomized trial, which found no difference in the risk of death or myocardial infarction by 1 year with or without thrombus aspiration among individuals with ST-elevation myocardial infarction. We benchmarked the emulation against the trial at 1 year and then extended the emulation's follow-up to 3 years and estimated effects in subpopulations underrepresented in the trial. As in the TASTE trial, the observational analysis found no differences in risk of outcomes by 1 year between groups (risk difference = 0.7 (confidence interval, -0.7, 2.0) and -0.2 (confidence interval, -1.3, 1.0) for death and myocardial infarction, respectively), so benchmarking was considered successful. We additionally showed no difference in risk of death or myocardial infarction by 3 years, or within subpopulations by 1 year. Benchmarking against an index trial before using observational analyses to answer questions beyond those the trial could address allowed us to explore whether the observational data can be trusted to deliver valid estimates of treatment effects.
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Affiliation(s)
- Anthony A Matthews
- Correspondence to Dr. Anthony A. Matthews, Institutet för Miljömedicin, Karolinska Institutet, Nobels väg 13, 171 65 Solna, Sweden (e-mail address: )
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20
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Kumar N, Janmohamed K, Nyhan K, Martins SS, Cerda M, Hasin D, Scott J, Sarpong Frimpong A, Pates R, Ghandour LA, Wazaify M, Khoshnood K. Substance, use in relation to COVID-19: A scoping review. Addict Behav 2022; 127:107213. [PMID: 34959077 PMCID: PMC8684053 DOI: 10.1016/j.addbeh.2021.107213] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/24/2021] [Accepted: 12/11/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND We conducted a scoping review focused on various forms of substance use amid the pandemic, looking at both the impact of substance use on COVID-19 infection, severity, and vaccine uptake, as well as the impact that COVID-19 has had on substance use treatment and rates. METHODS A scoping review, compiling both peer-reviewed and grey literature, focusing on substance use and COVID-19 was conducted on September 15, 2020 and again in April 15, 2021 to capture any new studies. Three bibliographic databases (Web of Science Core Collection, Embase, PubMed) and several preprint servers (EuropePMC, bioRxiv, medRxiv, F1000, PeerJ Preprints, PsyArXiv, Research Square) were searched. We included English language original studies only. RESULTS Of 1564 articles screened in the abstract and title screening phase, we included 111 research studies (peer-reviewed: 98, grey literature: 13) that met inclusion criteria. There was limited research on substance use other than those involving tobacco or alcohol. We noted that individuals engaging in substance use had increased risk for COVID-19 severity, and Black Americans with COVID-19 and who engaged in substance use had worse outcomes than white Americans. There were issues with treatment provision earlier in the pandemic, but increased use of telehealth as the pandemic progressed. COVID-19 anxiety was associated with increased substance use. CONCLUSIONS Our scoping review of studies to date during COVID-19 uncovered notable research gaps namely the need for research efforts on vaccines, COVID-19 concerns such as anxiety and worry, and low- to middle-income countries (LMICs) and under-researched topics within substance use, and to explore the use of qualitative techniques and interventions where appropriate. We also noted that clinicians can screen and treat individuals exhibiting substance use to mitigate effects of the pandemic. FUNDING Study was funded by the Institution for Social and Policy Studies, Yale University and The Horowitz Foundation for Social Policy. DH was funded by a NIDA grant (R01DA048860). The funding body had no role in the design, analysis, or interpretation of the data in the study.
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Affiliation(s)
- Navin Kumar
- Human Nature Lab, Department of Sociology, Yale University, New Haven, CT, USA.
| | | | - Kate Nyhan
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Silvia S Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Magdalena Cerda
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Deborah Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Jenny Scott
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | | | - Richard Pates
- Institute of Health and Society, University of Worcester, Worcester, UK
| | - Lilian A Ghandour
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Mayyada Wazaify
- Department of Biopharmaceuticals and Clinical Pharmacy, School of Pharmacy, University of Jordan, Amman, Jordan
| | - Kaveh Khoshnood
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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21
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Fadini GP, Del Prato S, Avogaro A, Solini A. Challenges and opportunities in real-world evidence on the renal effects of sodium-glucose cotransporter-2 inhibitors. Diabetes Obes Metab 2022; 24:177-186. [PMID: 34747123 PMCID: PMC9298781 DOI: 10.1111/dom.14599] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/27/2021] [Accepted: 11/04/2021] [Indexed: 12/25/2022]
Abstract
With increasing population aging and prevalence of type 2 diabetes (T2D) worldwide, prevention of diabetic complications remains a major unmet need. While cardiovascular outcomes of diabetes are improving over time, diabetic kidney disease (DKD) still leads to an exceedingly high rate of end-stage kidney disease (ESKD). A game-changing opportunity is offered by treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors. Randomized controlled trials (RCTs) have indisputably shown that SGLT2 inhibitors reduce the rate of DKD progression, the decline in estimated glomerular filtration rate (eGFR), and the development of ESKD. In parallel, SGLT2 inhibitors improve cardiovascular outcomes, especially the risk of hospitalization for heart failure. Real-world studies (RWSs) have largely confirmed the findings of RCTs in broader populations of subjects with T2D followed under routine care. In the present paper, we review RWSs exploring the renal effects of SGLT2 inhibitors and highlight the most critical challenges that can be encountered in designing and conducting such studies. Channelling bias (confounding by indication), time-lag bias, conditioning on the future, database heterogeneity, linearity of eGFR change over time, and duration of observation are critical issues that may undermine the robustness of RWS findings. We then elaborate on the new opportunities to overcome such limitations by describing the design and objectives of the DARWIN (DApagliflozin Real-World evIdeNce)-Renal study, a new RWS promoted by the Italian Diabetes Society. Fine-tuning of methods for comparative observational research will improve evidence derived from RWSs on the renal effects of SGLT2 inhibitors, aiding the evolving discussion regarding the place of SGLT2 inhibitors in T2D treatment algorithms in different stages of DKD.
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Affiliation(s)
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and DiabetesUniversity of PisaPisaItaly
| | | | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area PathologyUniversity of PisaPisaItaly
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22
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Zhu HH, Ma YF, Yu K, Ouyang GF, Luo WD, Pei RZ, Xu WQ, Hu HX, Mo SP, Xu XH, Lan JP, Shen JP, Shou LH, Qian SX, Feng WY, Zhao P, Jiang JH, Hu BL, Zhang J, Qian SY, Wu GQ, Wu WP, Qiu L, Li LJ, Lang XH, Chen S, Chen LL, Guo JB, Cao LH, Jiang HF, Xia YM, Le J, Zhao JZ, Huang J, Zhang YF, Lv YL, Hua JS, Hong YW, Zheng CP, Wang JX, Hu BF, Chen XH, Zhang LM, Tao S, Xie BS, Kuang YM, Luo WJ, Su P, Guo J, Wu X, Jiang W, Zhang HQ, Zhang Y, Chen CM, Xu XF, Guo Y, Tu JM, Hu S, Yan XY, Yao C, Lou YJ, Jin J. Early Death and Survival of Patients With Acute Promyelocytic Leukemia in ATRA Plus Arsenic Era: A Population-Based Study. Front Oncol 2021; 11:762653. [PMID: 34868978 PMCID: PMC8637823 DOI: 10.3389/fonc.2021.762653] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/21/2021] [Indexed: 11/23/2022] Open
Abstract
Most randomized trials for acute promyelocytic leukemia (APL) have investigated highly selected patients under idealized conditions, and the findings need to be validated in the real world. We conducted a population-based study of all APL patients in Zhejiang Province, China, with a total population of 82 million people, to assess the generalization of all-trans retinoic acid (ATRA) and arsenic as front-line treatment. The outcomes of APL patients were also analyzed. Between January 2015 and December 2019, 1,233 eligible patients were included in the final analysis. The rate of ATRA and arsenic as front-line treatment increased steadily from 66.2% in 2015 to 83.3% in 2019, with no difference among the size of the center (≥5 or <5 patients per year, p = 0.12) or age (≥60 or <60 years, p = 0.35). The early death (ED) rate, defined as death within 30 days after diagnosis, was 8.2%, and the 3-year overall survival (OS) was 87.9% in the whole patient population. Age (≥60 years) and white blood cell count (>10 × 109/L) were independent risk factors for ED and OS in the multivariate analysis. This population-based study showed that ATRA and arsenic as front-line treatment are widely used under real-world conditions and yield a low ED rate and a high survival rate, which mimic the results from clinical trials, thereby supporting the wider application of APL guidelines in the future.
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Affiliation(s)
- Hong-Hu Zhu
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Hematologic Malignancies, Diagnosis and Treatment, Hangzhou, China.,Zhejiang University Cancer Center, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Ya-Fang Ma
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Kang Yu
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Hangzhou, China
| | - Gui-Fang Ouyang
- Department of Hematology, Ningbo First Hospital, Ningbo, China
| | - Wen-Da Luo
- Department of Hematology, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Ren-Zhi Pei
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
| | - Wei-Qun Xu
- Department of Hematology, The Children's Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Hui-Xian Hu
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Shu-Ping Mo
- Department of Hematology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Xiao-Hua Xu
- Department of Hematology, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Jian-Ping Lan
- Department of Hematology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Jian-Ping Shen
- Department of Hematology, Zhejiang Provincial Hospital of Chinese Medicine, Hangzhou, China
| | - Li-Hong Shou
- Department of Hematology, Huzhou Central Hospital, Huzhou, China
| | - Shen-Xian Qian
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei-Ying Feng
- Department of Hematology, Shaoxing People's Hospital, Wenzhou, China
| | - Pu Zhao
- Department of Hematology, Ruian People's Hospital, Wenzhou, China
| | - Jin-Hong Jiang
- Department of Hematology, Lishui City People's Hospital, Lishui, China
| | - Bei-Li Hu
- Department of Hematology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Jin Zhang
- Department of Hematology, Sir Run Run Shaw Hospital (SRRSH) Affiliated with the Zhejiang University School of Medicine, Hangzhou, China
| | - Su-Ying Qian
- Department of Hematology, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Gong-Qiang Wu
- Department of Hematology, Dongyang Hospital Affiliated to Wenzhou Medical University, Jinhua, China
| | - Wen-Ping Wu
- Department of Hematology, People's Hospital of Quzhou, Quzhou, China
| | - Lei Qiu
- Department of Hematology, Zhoushan Hospital, Zhoushan, China
| | - Lin-Jie Li
- Department of Hematology, Lishui Municipal Central Hospital, Jinhua, China
| | - Xiang-Hua Lang
- Department of Hematology, The First People's Hospital of Yongkang, Jinhua, China
| | - Sai Chen
- Department of Hematology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
| | - Li-Li Chen
- Department of Hematology and Oncology, Taizhou First People's Hospital (Huangyan Hospital of Wenzhou Medical University), Taizhou, China
| | - Jun-Bin Guo
- Department of Hematology and Oncology, The First People's Hospital of Wenling, Taizhou, China
| | - Li-Hong Cao
- Department of Hematology, Shulan Hospital, Hangzhou, China
| | - Hui-Fang Jiang
- Department of Hematology, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Yong-Ming Xia
- Department of Hematology, Rheumatology and Nephrology, Yuyao People's Hospital, Ningbo University Yangming Affiliated Hospital, Ningbo, China
| | - Jing Le
- Department of Hematology and Oncology, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Jian-Zhi Zhao
- Department of Hematology, Shaoxing Central Hospital, Shaoxing, China
| | - Jian Huang
- Department of Hematology, The Fourth Affiliated Hospital Zhejiang University School of Medicine, Jinhua, China
| | - Yue-Feng Zhang
- Department of Hematology, The First People's Hospital of Yuhang District, Hangzhou, China
| | - Ya-Li Lv
- Department of Hematology, Xinchang People's Hospital, Shaoxing, China
| | - Jing-Sheng Hua
- Department of Hematology and Oncology, Taizhou Municipal Hospital, Taizhou, China
| | - Yong-Wei Hong
- Department of Hematology, Ningbo Yinzhou No. 2 Hospital, Ningbo, China
| | - Cui-Ping Zheng
- Department of Hematotherapeutic, Wenzhou Central Hospital Medical Group, Wenzhou, China
| | - Ju-Xiang Wang
- Department of Hematology and Oncology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bin-Fei Hu
- Department of Pediatric Hematology, Ningbo Women and Children's Hospital, Ningbo, China
| | - Xiao-Hui Chen
- Department of Hematology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Li-Ming Zhang
- Department of Hematology, Zhuji People's Hospital, Shaoxing, China
| | - Shi Tao
- Department of Hematology, Shaoxing Second Hospital, Shaoxing, China
| | - Bing-Shou Xie
- Department of Hematology, Wenzhou People's Hospital, Wenzhou, China
| | - Yue-Min Kuang
- Department of Hematology, Jinhua People's Hospital, Jinhua, China
| | - Wen-Ji Luo
- Department of Hematology, The First People's Hospital of Xiaoshan District, Hangzhou, China
| | - Ping Su
- Department of Hematology, Zhejiang Xiaoshan Hospital, Hangzhou, China
| | - Jun Guo
- Department of Hematology and Oncology, The Sencond Affiliated Hospital of Zhejiang University, SAHZU Changxing Branch, Huzhou, China
| | - Xiao Wu
- Department of Oncology and Hematology, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
| | - Wei Jiang
- Department of Hematology, Shangyu People's Hospital, Shaoxing, China
| | - Hui-Qi Zhang
- Department of Hematology, The First People's Hospital of Huzhou, Huzhou, China
| | - Yun Zhang
- Department of Hematotherapeutic, Yueqing People's Hospital, Wenzhou, China
| | - Chun-Mei Chen
- Department of Hematotherapeutic, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiao-Feng Xu
- Department of Oncology and Hematology, Hangzhou Red Cross Hospital, Hangzhou, China
| | - Yan Guo
- Department of Hematology, The First People's Hospital of Pinghu, Jiaxing, China
| | - Jin-Ming Tu
- Department of Gastroenterology and Hematology, Longyou People's Hospital, Quzhou, China
| | - Shao Hu
- Department of Hematology and Oncology, The First Hospital of Ninghai County, Ningbo, China
| | - Xiao-Yan Yan
- Department of Biostatistics, Peking University Clinical Research Institute, Beijing, China
| | - Chen Yao
- Department of Biostatistics, Peking University Clinical Research Institute, Beijing, China
| | - Yin-Jun Lou
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Hematologic Malignancies, Diagnosis and Treatment, Hangzhou, China.,Zhejiang University Cancer Center, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
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23
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Longato E, Di Camillo B, Sparacino G, Tramontan L, Avogaro A, Fadini GP. Cardiovascular outcomes after initiating GLP-1 receptor agonist or basal insulin for the routine treatment of type 2 diabetes: a region-wide retrospective study. Cardiovasc Diabetol 2021; 20:222. [PMID: 34774054 PMCID: PMC8590792 DOI: 10.1186/s12933-021-01414-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/04/2021] [Indexed: 01/17/2023] Open
Abstract
Aim We aimed to compare cardiovascular outcomes of patients with type 2 diabetes (T2D) who initiated GLP-1 receptor agonists (GLP-1RA) or basal insulin (BI) under routine care. Methods We accessed the administrative claims database of the Veneto Region (Italy) to identify new users of GLP-1RA or BI in 2014–2018. Propensity score matching (PSM) was implemented to obtain two cohorts of patients with superimposable characteristics. The primary endpoint was the 3-point major adverse cardiovascular events (3P-MACE). Secondary endpoints included 3P-MACE components, hospitalization for heart failure, revascularizations, and adverse events. Results From a background population of 5,242,201 citizens, 330,193 were identified as having diabetes. PSM produced two very well matched cohorts of 4063 patients each, who initiated GLP-1RA or BI after an average of 2.5 other diabetes drug classes. Patients were 63-year-old and only 15% had a baseline history of cardiovascular disease. During a median follow-up of 24 months in the intention-to-treat analysis, 3P-MACE occurred less frequently in the GLP-1RA cohort (HR versus BI 0.59; 95% CI 0.50–0.71; p < 0.001). All secondary cardiovascular endpoints were also significantly in favor of GLP-1RA. Results were confirmed in the as-treated approach and in several stratified analyses. According to the E-value, confounding by unmeasured variables were unlikely to entirely explain between-group differences in cardiovascular outcomes. Conclusions Patients with T2D who initiated a GLP-1RA experienced far better cardiovascular outcomes than did matched patients who initiated a BI in the same healthcare system. These finding supports prioritization of GLP-1RA as the first injectable regimen for the management of T2D. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01414-3.
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Affiliation(s)
- Enrico Longato
- Department of Information Engineering, University of Padova, 35100, Padova, Italy
| | - Barbara Di Camillo
- Department of Information Engineering, University of Padova, 35100, Padova, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, University of Padova, 35100, Padova, Italy
| | - Lara Tramontan
- Arsenàl.IT, Veneto's Research Centre for eHealth Innovation, 31100, Treviso, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100, Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100, Padova, Italy.
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24
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Moreau Bachelard C, Coquan E, du Rusquec P, Paoletti X, Le Tourneau C. Risks and benefits of anticancer drugs in advanced cancer patients: A systematic review and meta-analysis. EClinicalMedicine 2021; 40:101130. [PMID: 34746718 PMCID: PMC8548931 DOI: 10.1016/j.eclinm.2021.101130] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/14/2022] Open
Abstract
UNLABELLED Background: Randomized clinical trials (RCTs) of anticancer drugs without active comparators in patients who have exhausted standard of care treatment options are debated. We aimed to quantify the safety and the efficacy of anticancer drugs in advanced cancer patients who have exhausted standard of care treatments from RCTs without active comparators.Methods: This systematic review and meta-analysis was conducted according to preferred reporting Items for systematic review and Meta-Analyses (PRISMA) guidelines (CRD42021243968). A systematic literature search of English language publications from January 1, 2000, to January 7, 2021, was performed using MEDLINE (PubMed). Eligible trials included all RCTs evaluating anticancer drugs in adult patients with advanced solid tumors with a control arm without any anticancer drug consisting of best supportive care with or without a placebo. RCTs performed in the adjuvant, neoadjuvant or maintenance settings were excluded, as were clinical trials evaluating anticancer drugs in combination with radiotherapy. Two authors (C.M.B. and E.C.) independently reviewed the studies for inclusion. Data from published reports were extracted by investigators, and random-effects meta-analysis was performed to estimate the overall hazard ratios (HRs) of progression-free survival (PFS) and overall survival (OS). Correlations between severe toxicity and efficacy was assessed using R2 measures.Findings: Of 3551 studies screened, 128 eligible trials were found involving 47,432 patients. The HRs for PFS and OS were 0·58 [95%CI: 0·53-0·63] and 0·82 [95%CI: 0·78-0·85]. The absolute benefits however were limited with PFS and OS gains of 2·1 and 0·5 months. The absolute excesses in all grade, severe grade III, IV and V (death) adverse events between the two arms were +13·9%, 10·2%, and +0·5%. A weak correlation was measured between the excess of severe toxicity and efficacy (all R² < 0·2).Interpretation: Anticancer drugs evaluated in RCTs against no active treatment benefited trial participants. Severe toxicity did not significantly correlate with efficacy. FUNDING None.
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Affiliation(s)
- Camille Moreau Bachelard
- Department of Drug Development and innovation (D3i), Institut Curie, Paris and Saint-Cloud, 26, rue d'Ulm, Paris 75005, France
- Department of Medical Oncology, Institut de Cancerologie de l'Ouest, Nantes, France
| | - Elodie Coquan
- Department of Medical Oncology, Center François Baclesse, Caen, France
| | - Pauline du Rusquec
- Department of Drug Development and innovation (D3i), Institut Curie, Paris and Saint-Cloud, 26, rue d'Ulm, Paris 75005, France
- INSERM U900 Research unit, Saint-Cloud, France
| | - Xavier Paoletti
- INSERM U900 Research unit, Saint-Cloud, France
- Paris-Saclay University, Paris, France
| | - Christophe Le Tourneau
- Department of Drug Development and innovation (D3i), Institut Curie, Paris and Saint-Cloud, 26, rue d'Ulm, Paris 75005, France
- INSERM U900 Research unit, Saint-Cloud, France
- Paris-Saclay University, Paris, France
- Corresponding author at: Department of Drug Development and innovation (D3i), Institut Curie, Paris and Saint-Cloud, 26, rue d'Ulm, Paris 75005, France.
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Diemer F, Zebisch J, Saueressig T. [Consequences of anterior cruciate ligament rupture: a systematic umbrella review]. SPORTVERLETZUNG-SPORTSCHADEN 2021; 36:18-37. [PMID: 34544171 DOI: 10.1055/a-1474-8986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The treatment of an anterior cruciate ligament rupture is still controversial. In particular, this applies to the question of conservative versus surgical treatment. The answer to this question is often based on consequential damage such as the development of posttraumatic osteoarthritis, secondary damage to the meniscus or cartilage, and participation in sports. If there are significant differences in these parameters between the individual treatment options, the results will be of great importance for the development of evidence-based treatment pathways. Therefore, the aim of this work was to evaluate the development of knee osteoarthritis after rupture of the anterior cruciate ligament and the corresponding treatment (conservative or surgical). MATERIAL AND METHODS To answer the above question, a systematic literature search was conducted in Medline via Pubmed, the Cochrane Library and in CINAHL. Only systematic reviews with a minimum follow-up period of 10 years were included. The search was conducted in January 2020 and updated in January 2021. Investigated cohorts included patients with a rupture of the anterior cruciate ligament who had undergone either conservative or surgical treatment. Osteoarthritis was diagnosed either radiologically (recognized scores) or clinically (pain and impaired function). Appropriate reviews were qualitatively evaluated using the AMSTAR-2 questionnaire. RESULTS The literature research initially identified n = 42 reviews from which 14 reviews were included. After full-text review and qualitative evaluation, only n = 2 systematic reviews remained for evaluation. The results of both papers show imprecise data with a high variability. However, it can be assumed with high probability that the development of osteoarthritis of the knee is increased after a rupture of the anterior cruciate ligament. There is no evidence that the incidence of joint degeneration may be reduced by reconstruction of the anterior cruciate ligament, nor is there a difference when comparing conservative and surgical treatment directly. CONCLUSION Patients with an anterior cruciate ligament rupture are likely to be at a greater risk of developing progressive joint degeneration. A protective effect of cruciate ligament surgery has not been found in the evaluated studies. A general argument in favour of cruciate ligament surgery aiming to achieve a protective effect on hyaline articular cartilage seems obsolete based on the results and should therefore not be used in patient education in the future.
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Affiliation(s)
- Frank Diemer
- DIGOTOR GbR, Brackenheim, Germany.,Physio Meets Science GmbH, Leimen, Germany
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Paoletti G, Di Bona D, Chu DK, Firinu D, Heffler E, Agache I, Jutel M, Klimek L, Pfaar O, Mösges R, DunnGalvin A, Genuneit J, Hoffmann HJ, Canonica GW. Allergen immunotherapy: The growing role of observational and randomized trial "Real-World Evidence". Allergy 2021; 76:2663-2672. [PMID: 33583050 DOI: 10.1111/all.14773] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although there is a considerable body of knowledge about allergen immunotherapy (AIT), there is a lack of data on the reliability of real-world evidence (RWE) in AIT, and consequently, a lack of information on how AIT effectively works in real life. METHODS To address the current unmet need for an appraisal of the quality of RWE in AIT, the European Academy of Allergy and Clinical Immunology Methodology Committee recently initiated a systematic review of observational studies of AIT, which will use the RELEVANT tool and the Grading of Recommendations Assessment, Development and Evaluation approach (GRADE) to rate the quality of the evidence base as a whole. The next step will be to develop a broadly applicable, pragmatic "real-world" database using systematic data collection. Based on the current RWE base, and perspectives and recommendations of authorities and scientific societies, a hierarchy of RWE in AIT is proposed, which places pragmatic trials and registry data at the positions of highest level of evidence. KEY RESULTS There is a need to establish more AIT registries that collect data in a cohesive way, using standardized protocols. CONCLUSIONS This will provide an essential source of real-world data that can be easily shared, promoting evidence-based research and quality improvement in study design and clinical decision-making.
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Affiliation(s)
- Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy Humanitas Clinical and Research Center IRCCS and Department of Biomedical Sciences Humanitas University Milan Italy
| | - Danilo Di Bona
- Department of Emergency and Organ Transplantation School and Chair of Allergology and Clinical Immunology University of Bari – Aldo Moro Bari Italy
| | - Derek K. Chu
- Division of Immunology and Allergy Department of Health Research Methods, Evidence and Impact Department of Medicine McMaster University Hamilton ON Canada
- The Research Institute of St. Joe's Hamilton Hamilton ON Canada
| | - Davide Firinu
- Department of Clinical Sciences and Public Health University of Cagliari Cagliari Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy Humanitas Clinical and Research Center IRCCS and Department of Biomedical Sciences Humanitas University Milan Italy
| | - Ioana Agache
- Department of Allergy and Clinical Immunology Faculty of Medicine Transylvania University of Brasov Brasov Romania
| | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University and “ALLMED”Medical Research Institute Wroclaw Poland
| | - Ludger Klimek
- Center for Rhinology and Allergology Wiesbaden Germany
| | - Oliver Pfaar
- Section of Rhinology and Allergy Department of Otorhinolaryngology, Head and Neck Surgery University Hospital MarburgPhilipps‐Universität Marburg Marburg Germany
| | - Ralph Mösges
- Faculty of Medicine Institute of Medical Statistics and Computational Biology (IMSB) University of Cologne and CRI – Clinical Research International Limited Cologne Germany
| | - Audrey DunnGalvin
- School of Applied Psychology and Department of Paediatrics & Child Health University College Cork Cork Ireland
| | - Jon Genuneit
- Institute of Epidemiology and Medical Biometry Ulm University Ulm Germany
- Pediatric Epidemiology, Department of Pediatrics, Medical Faculty Leipzig University Leipzig Germany
| | - Hans Jürgen Hoffmann
- Department of Clinical Medicine Aarhus University and Department of Respiratory Diseases and AllergyAarhus University Hospital Aarhus Denmark
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy Humanitas Clinical and Research Center IRCCS and Department of Biomedical Sciences Humanitas University Milan Italy
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Kent S, Salcher-Konrad M, Boccia S, Bouvy JC, Waure CD, Espin J, Facey K, Nguyen M, Rejon-Parrilla JC, Jonsson P. The use of nonrandomized evidence to estimate treatment effects in health technology assessment. J Comp Eff Res 2021; 10:1035-1043. [PMID: 34279114 DOI: 10.2217/cer-2021-0108] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Health technology assessment (HTA) is increasingly informed by nonrandomized studies, but there is limited guidance from HTA bodies on expectations around evidence quality and study conduct. We developed recommendations to support the appropriate use of such evidence based on a pragmatic literature review and a workshop involving 16 experts from eight countries as part of the EU's Horizon-2020 IMPACT-HTA program (work package six). To ensure HTA processes remain rigorous and robust, HTA bodies should demand clear, extensive and structured reporting of nonrandomized studies, including an in-depth assessment of the risk of bias. In recognition of the additional uncertainty imparted by nonrandomized designs in estimates of treatment effects, HTA bodies should strengthen early scientific advice and engage in collaborative efforts to improve use of real-world data.
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Affiliation(s)
- Seamus Kent
- National Institute for Health & Care Excellence, Manchester, M1 4BT, UK
| | - Maximilian Salcher-Konrad
- Care Policy & Evaluation Center (CPEC), London School of Economics & Political Science, London, WC2A 2AE, UK.,LSE Health, London School of Economics & Political Science, London, WC2A 2AE, UK
| | - Stefania Boccia
- Section of Hygiene, University Department of Life Sciences & Public Health, Università Cattolica del Sacro Cuore, Rome, 20123, Italy.,Department of Woman & Child Health & Public Health - Public Health Area, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome RM, 00168, Italy
| | - Jacoline C Bouvy
- National Institute for Health & Care Excellence, Manchester, M1 4BT, UK
| | - Chiara de Waure
- Department of Medicine & Surgery, University of Perugia, Perugia, 06123, Italy
| | - Jaime Espin
- Andalusian School of Public Health/Escuela Andaluza de Salud Pública (EASP), Granada, 18011, Spain.,CIBER en Epidemiología y Salud Pública (CIBERESP), Spain / CIBER of Epidemiology & Public Health (CIBERESP), Planta 0, Madrid, 28029 Spain.,Instituto de Investigación Biosanitaria ibs, Granada, 18012, Spain
| | - Karen Facey
- Usher Institute, University of Edinburgh, Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | - Mary Nguyen
- LSE Health, London School of Economics & Political Science, London, WC2A 2AE, UK
| | | | - Pall Jonsson
- National Institute for Health & Care Excellence, Manchester, M1 4BT, UK
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28
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Bonora BM, Avogaro A, Fadini GP. Disentangling conflicting evidence on DPP-4 inhibitors and outcomes of COVID-19: narrative review and meta-analysis. J Endocrinol Invest 2021; 44:1379-1386. [PMID: 33512688 PMCID: PMC7845283 DOI: 10.1007/s40618-021-01515-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/19/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly spread all over the world, becoming pandemic. Several studies have shown that diabetes mellitus (DM) is an independent risk factor that increases mortality and other adverse outcomes of coronavirus disease-19 (COVID-19). Studies have suggested that SARS-CoV-2 may bind dipeptidyl peptidase-4 (DPP4) for entering cells of the respiratory tract. Besides, DPP4 takes part in immune system regulation. Thus, DPP-4 inhibitors (DPP4i) may play a role against COVID-19. METHODS We focused on the impact of DPP4i treatment on COVID-19-related outcomes in people with DM. For this purpose, we conducted a systematic review and meta-analysis to summarize the existing evidence on this topic. RESULTS Retrospective observational studies provide inconsistent results on the association between use of DPP4i and outcomes of COVID-19. While two studies reported significantly lower mortality rates among patients with DM who received DPP4i versus those who did not, a series of other studies showed no effect of DPP4i or even worse outcomes. A meta-analysis of 7 studies yielded a neutral estimate of the risk ratio of COVID-19-related mortality among users of DPP4i (0.81; 95% CI 0.57-1.15). CONCLUSION In the absence of randomized controlled trials, observational research available so far provides inconclusive results and insufficient evidence to recommend use of DPP4i against COVID-19.
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Affiliation(s)
- B M Bonora
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - A Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - G P Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
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29
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Matthews AA, Szummer K, Dahabreh IJ, Lindahl B, Erlinge D, Feychting M, Jernberg T, Berglund A, Hernán MA. Comparing Effect Estimates in Randomized Trials and Observational Studies From the Same Population: An Application to Percutaneous Coronary Intervention. J Am Heart Assoc 2021; 10:e020357. [PMID: 33998290 PMCID: PMC8483524 DOI: 10.1161/jaha.120.020357] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background To understand when results from observational studies and randomized trials are comparable, we performed an observational emulation of a target trial designed to ask similar questions as the VALIDATE (Bivalirudin Versus Heparin in ST‐Segment and Non–ST‐Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy) randomized trial. The VALIDATE trial compared the effect of bivalirudin and heparin during percutaneous coronary intervention on the risk of death, myocardial infarction, and bleeding across Sweden. Methods and Results We specified the protocol of a target trial similar to the VALIDATE trial, then emulated the target trial in the period before the VALIDATE trial took place using data from the SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) registry—the same registry in which the trial was undertaken. The target trial emulation and the VALIDATE trial both estimated little or no effect of bivalirudin versus heparin on the risk of death or myocardial infarction by 180 days (target trial emulation risk ratio for death, 1.21 [95% CI, 0.88 – 1.54]; VALIDATE trial hazard ratio for death, 1.05 [95% CI, 0.78 – 1.41]). The observational data, however, could not capture less severe cases of bleeding, resulting in an inability to define a bleeding outcome like the trial, and could not accurately estimate the comparative risk of death by 14 days, which may be the result of intractable confounding early in follow‐up or the inability to precisely emulate the trial’s eligibility criteria. Conclusions Using real‐world data to emulate a target trial can deliver accurate effect estimates. Yet, even with rich observational data, it is not always possible to estimate the short‐term effect of interventions or the effect on outcomes for which data are not routinely collected.
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Affiliation(s)
- Anthony A Matthews
- Unit of Epidemiology Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Karolina Szummer
- Department of Cardiology Karolinska University Hospital Stockholm Sweden.,Department of Medicine Karolinska Institutet Huddinge Sweden
| | - Issa J Dahabreh
- Department of Biostatistics Harvard T.H. Chan School of Public Health Boston MA.,Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - David Erlinge
- Department of Cardiology Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - Maria Feychting
- Unit of Epidemiology Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences Danderyd University Hospital-Karolinska Institute Danderyd Sweden
| | - Anita Berglund
- Unit of Epidemiology Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Miguel A Hernán
- Unit of Epidemiology Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden.,Department of Biostatistics Harvard T.H. Chan School of Public Health Boston MA.,Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA.,Harvard-MIT Division of Health Sciences and Technology Boston MA
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Taylor SP, Kowalkowski MA, Admon AJ. Timing Is Everything. The Importance of Alignment of Time Anchors for Observational Causal Inference Research. Ann Am Thorac Soc 2021; 18:769-772. [PMID: 33217239 PMCID: PMC8086541 DOI: 10.1513/annalsats.202009-1163vp] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/20/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - Marc A. Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina; and
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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31
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Norrbacka K, Sicras-Mainar A, Lebrec J, Artime E, Díaz S, Tofé-Povedano S, Hernández I, Romera I. Glucagon-Like Peptide 1 Receptor Agonists in Type 2 Diabetes Mellitus: Data from a Real-World Study in Spain. Diabetes Ther 2021; 12:1535-1551. [PMID: 33860927 PMCID: PMC8099971 DOI: 10.1007/s13300-021-01039-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/23/2021] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION This study aimed to describe utilization patterns, persistence, resource utilization and costs in patients with type 2 diabetes mellitus initiating treatment with glucagon-like peptide 1 receptor agonists in routine clinical practice in Spain. METHODS This retrospective study of medical records in the Big-Pac database identified adults starting treatment with once-weekly (QW) dulaglutide, exenatide-QW or once-daily liraglutide between 1 November 2015 and 30 June 2017. Patients were followed for up to 18 months from treatment initiation. Data on clinical characteristics of patients, treatment patterns, average daily dose and costs were obtained for the three cohorts. Persistence over the 18-month period was evaluated using Kaplan-Meier curves. All analyses were descriptive. RESULTS A total of 1402 patients were included in this study (dulaglutide [n = 492], exenatide-QW [n = 438] or liraglutide [n = 472]); 52.8% were men, and the mean (SD) age was 62 (11) years, glycated haemoglobin (HbA1c) was 8.1% (1.2) and body mass index was 35.5 (3.2) kg/m2 at treatment initiation. Persistence at 18 months was 59.1% (95% confidence interval [CI] 54.8-63.4) for dulaglutide, 45.7% (95% CI 41.0-50.4) for exenatide-QW and 46.6% (95% CI 42.1-51.1) for liraglutide. The average (SD) dose was 1.2 (0.4) mg/week for dulaglutide, 1.9 (0.3) mg/week for exenatide-QW and 1.1 (0.3) mg/day for liraglutide. The average reduction in HbA1c levels at 1 year was - 0.68% for patients who initiated dulaglutide, - 0.54% for patients who initiated exenatide-QW and - 0.50% for patients who initiated liraglutide. The mean (SD) total annual health care costs were €4072 (1946) for dulaglutide, €4418 (2382) for exenatide-QW and €4382 (2389) for liraglutide. CONCLUSION Results suggest that patients who started treatment with dulaglutide had higher persistence over 18 months, presented lower HbA1c levels at 12 months and incurred lower annual total healthcare costs than patients who initiated exenatide-QW or liraglutide.
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Affiliation(s)
| | | | | | - Esther Artime
- Lilly Spain, Avenida de la Industria 30, Alcobendas, Madrid, Spain
| | - Silvia Díaz
- Lilly Spain, Avenida de la Industria 30, Alcobendas, Madrid, Spain
| | | | | | - Irene Romera
- Lilly Spain, Avenida de la Industria 30, Alcobendas, Madrid, Spain
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Schuemie MJ, Ryan PB, Pratt N, Chen R, You SC, Krumholz HM, Madigan D, Hripcsak G, Suchard MA. Large-scale evidence generation and evaluation across a network of databases (LEGEND): assessing validity using hypertension as a case study. J Am Med Inform Assoc 2021; 27:1268-1277. [PMID: 32827027 PMCID: PMC7481033 DOI: 10.1093/jamia/ocaa124] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/02/2020] [Accepted: 06/01/2020] [Indexed: 01/12/2023] Open
Abstract
Objectives To demonstrate the application of the Large-scale Evidence Generation and
Evaluation across a Network of Databases (LEGEND) principles described in
our companion article to hypertension treatments and assess internal and
external validity of the generated evidence. Materials and Methods LEGEND defines a process for high-quality observational research based on 10
guiding principles. We demonstrate how this process, here implemented
through large-scale propensity score modeling, negative and positive control
questions, empirical calibration, and full transparency, can be applied to
compare antihypertensive drug therapies. We assess internal validity through
covariate balance, confidence-interval coverage, between-database
heterogeneity, and transitivity of results. We assess external validity
through comparison to direct meta-analyses of randomized controlled trials
(RCTs). Results From 21.6 million unique antihypertensive new users, we generate
6 076 775 effect size estimates for 699 872 research
questions on 12 946 treatment comparisons. Through propensity score
matching, we achieve balance on all baseline patient characteristics for
75% of estimates, observe 95.7% coverage in our
effect-estimate 95% confidence intervals, find high between-database
consistency, and achieve transitivity in 84.8% of triplet
hypotheses. Compared with meta-analyses of RCTs, our results are consistent
with 28 of 30 comparisons while providing narrower confidence intervals. Conclusion We find that these LEGEND results show high internal validity and are
congruent with meta-analyses of RCTs. For these reasons we believe that
evidence generated by LEGEND is of high quality and can inform medical
decision-making where evidence is currently lacking. Subsequent publications
will explore the clinical interpretations of this evidence.
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Affiliation(s)
- Martijn J Schuemie
- Epidemiology Analytics, Janssen Research and Development, Titusville, New Jersey, USA.,Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA
| | - Patrick B Ryan
- Epidemiology Analytics, Janssen Research and Development, Titusville, New Jersey, USA.,Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, Adelaide, Australia
| | - RuiJun Chen
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Seng Chan You
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea
| | - Harlan M Krumholz
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David Madigan
- Department of Statistics, Columbia University, New York, New York, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA.,Medical Informatics Services, New York-Presbyterian Hospital, New York, New York, USA
| | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA.,Department of Biomathematics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California, USA
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Bergqvist C, Stern R, Chosidow O. Psoriasis: an example of the complexity of decision making. Br J Dermatol 2021; 185:195-197. [DOI: 10.1111/bjd.19715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 02/04/2023]
Affiliation(s)
- C. Bergqvist
- Département de Dermatologie AP‐HPHôpitaux universitaires Henri MondorUPEC CréteilF‐94010France
| | - R.S. Stern
- Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA USA
| | - O. Chosidow
- Département de Dermatologie AP‐HPHôpitaux universitaires Henri MondorUPEC CréteilF‐94010France
- Research Group Dynamic EA7380 Faculté de Santé de Créteil Ecole nationale vétérinaire d’AlfortUSC ANSESUniversité Paris‐Est Créteil Créteil France
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Fanaroff AC, Califf RM, Harrington RA, Granger CB, McMurray JJV, Patel MR, Bhatt DL, Windecker S, Hernandez AF, Gibson CM, Alexander JH, Lopes RD. Randomized Trials Versus Common Sense and Clinical Observation: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 76:580-589. [PMID: 32731936 PMCID: PMC7384793 DOI: 10.1016/j.jacc.2020.05.069] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/11/2022]
Abstract
Concerns about the external validity of traditional randomized clinical trials (RCTs), together with the widespread availability of real-world data and advanced data analytic tools, have led to claims that common sense and clinical observation, rather than RCTs, should be the preferred method to generate evidence to support clinical decision-making. However, over the past 4 decades, results from well-done RCTs have repeatedly contradicted practices supported by common sense and clinical observation. Common sense and clinical observation fail for several reasons: incomplete understanding of pathophysiology, biases and unmeasured confounding in observational research, and failure to understand risks and benefits of treatments within complex systems. Concerns about traditional RCT models are legitimate, but randomization remains a critical tool to understand the causal relationship between treatments and outcomes. Instead, development and promulgation of tools to apply randomization to real-world data are needed to build the best evidence base in cardiovascular medicine. Well-conducted RCTs have repeatedly contradicted practices supported by common sense and clinical observation. Common sense and clinical observation fail because of the inability to fully understand complex biopsychosocial systems. RCTs must be integrated into clinical practice to improve the evidence base in cardiology.
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Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, Pennsylvania. https://twitter.com/ACFanaroff
| | - Robert M Califf
- Verily Life Sciences (Alphabet), South San Francisco, California
| | | | - Christopher B Granger
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland
| | - Manesh R Patel
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Adrian F Hernandez
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - C Michael Gibson
- Cardiovascular Division, Beth Israel Deaconess Medical, Harvard Medical School, Boston, Massachusetts
| | - John H Alexander
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Renato D Lopes
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina.
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35
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Wolfenden L, Foy R, Presseau J, Grimshaw JM, Ivers NM, Powell BJ, Taljaard M, Wiggers J, Sutherland R, Nathan N, Williams CM, Kingsland M, Milat A, Hodder RK, Yoong SL. Designing and undertaking randomised implementation trials: guide for researchers. BMJ 2021; 372:m3721. [PMID: 33461967 PMCID: PMC7812444 DOI: 10.1136/bmj.m3721] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Implementation science is the study of methods to promote the systematic uptake of evidence based interventions into practice and policy to improve health. Despite the need for high quality evidence from implementation research, randomised trials of implementation strategies often have serious limitations. These limitations include high risks of bias, limited use of theory, a lack of standard terminology to describe implementation strategies, narrowly focused implementation outcomes, and poor reporting. This paper aims to improve the evidence base in implementation science by providing guidance on the development, conduct, and reporting of randomised trials of implementation strategies. Established randomised trial methods from seminal texts and recent developments in implementation science were consolidated by an international group of researchers, health policy makers, and practitioners. This article provides guidance on the key components of randomised trials of implementation strategies, including articulation of trial aims, trial recruitment and retention strategies, randomised design selection, use of implementation science theory and frameworks, measures, sample size calculations, ethical review, and trial reporting. It also focuses on topics requiring special consideration or adaptation for implementation trials. We propose this guide as a resource for researchers, healthcare and public health policy makers or practitioners, research funders, and journal editors with the goal of advancing rigorous conduct and reporting of randomised trials of implementation strategies.
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Affiliation(s)
- Luke Wolfenden
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Noah M Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Department of Family Medicine and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Byron J Powell
- Brown School and School of Medicine, Washington University in St Louis, St Louis, MI, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - John Wiggers
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Rachel Sutherland
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Nicole Nathan
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Christopher M Williams
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Kingsland
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Andrew Milat
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca K Hodder
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Sze Lin Yoong
- Swinburne University of Technology, School of Health Sciences, Faculty Health, Arts and Design, Hawthorn, VIC, Australia
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Kumar N, Janmohamed K, Jiang J, Ainooson J, Billings A, Chen GQ, Chumo F, Cueto L, Niaura R, Zhang A. Tobacco cessation in low- to middle-income countries: A scoping review of randomized controlled trials. Addict Behav 2021; 112:106612. [PMID: 33002679 DOI: 10.1016/j.addbeh.2020.106612] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/24/2020] [Accepted: 08/15/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The growing prevalence of tobacco use in low "to middle" income countries (LMICs) and the hurdles of conducting tobacco cessation in that context necessitates a focus on the scope of randomized controlled trials (RCTs) in LMICs to guide tobacco cessation in this environment. We conducted a scoping review to identify LMIC tobacco cessation RCTs. METHODS Consistent with PRISMA-ScR guidelines and without language restrictions, we systematically searched peer-reviewed databases (MEDLINE, Embase, PsycINFO, articles published since inception, latest searches in March 2020) and gray literature (clinical trials registries, searches between September and December 2019). We searched for data on RCT type, outcome significance and intervention description. Inclusion: research conducted in LMICs; tobacco cessation; RCT. Exclusion: research conducted in high income countries; non-RCT; studies involving only those aged <18. Data was extracted from published reports. We generated narrative summaries of each LMIC's tobacco cessation RCT research environment. RESULTS Of 8404 articles screened, we identified 92 studies. Tobacco cessation RCTs were recorded in 16 of 138 countries/territories in LMICs. Evidence was weak in quality and severely limited. Most RCTs were psychosocial, with limited behavioral and pharmacological variants. CONCLUSIONS Tobacco control within LMICs is essential to reduce the tobacco mortality burden. Researchers should be cognizant that tobacco cessation in LMICs is still not an environment where best practice has been established. We suggest that developing solutions specific for LMICs is key to effective tobacco control in LMICs.
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Boden WE, Bhatt DL. Translating the findings of ISCHEMIA into clinical practice: a challenging START. EUROINTERVENTION 2020; 16:e953-e956. [DOI: 10.4244/eijv16i12a174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lanza G, Giannandrea D, Lanza J, Ricci S, Gensini GF. Personalized-medicine on carotid endarterectomy and stenting. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1274. [PMID: 33178806 PMCID: PMC7607117 DOI: 10.21037/atm-20-1126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Evidence based medicine (EBM) is the core of current clinical guidelines and is considered as the gold standard of clinical practice. Despite this, a number of limitations and criticisms are moved to EBM. The major one is that this method privileges randomized controlled trials (RCTs), in which the selection of patients is often based on rigid inclusion criteria. The lack of “pragmatism” of some RCTs sometimes makes it difficult to apply guidelines that derive from them to patients observed in clinical practice, who are often affected by comorbidities and disabilities. The new paradigm to overcome this limitation is personalized medicine (PM), which aims to take into account the particular characteristics displayed by the individual. In order to tailor the best treatment for the patient, PM uses EBM but emphasizes the person's specific information from the assessment of the clinic, lifestyle and risk/benefit scores. This narrative review tries to find the best evidence by analysing subgroups and risk scores of patients from meta-analysis and RCTs in order to try to apply PM and to provide good practice points (GPP) on grey aspects and open questions not fully covered by current guidelines on carotid endarterectomy (CEA) and stenting for stroke prevention.
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Affiliation(s)
- Gaetano Lanza
- Vascular Surgery Department, IRCCS MultiMedica Hospital, Castellanza, Italy
| | - David Giannandrea
- Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy.,Association "Naso Sano", Umbria Regional Registry of No-Profit Organization, Corciano, Italy
| | - Jessica Lanza
- ASST Fatebenefratelli Sacco, Angioma Center, Vittore Buzzi Hospital, Milan, Italy
| | - Stefano Ricci
- Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | - Gian Franco Gensini
- Permanent Technical Committee for Guidelines, Tuscany Regional Health Service, Florence, Italy
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Consoli A, Czupryniak L, Duarte R, Jermendy G, Kautzky-Willer A, Mathieu C, Melo M, Mosenzon O, Nobels F, Papanas N, Roman G, Schnell O, Sotiropoulos A, Stehouwer CDA, Tack CJ, Woo V, Fadini GP, Raz I. Positioning sulphonylureas in a modern treatment algorithm for patients with type 2 diabetes: Expert opinion from a European consensus panel. Diabetes Obes Metab 2020; 22:1705-1713. [PMID: 32476244 DOI: 10.1111/dom.14102] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/15/2020] [Accepted: 05/27/2020] [Indexed: 12/21/2022]
Abstract
The large number of pharmacological agents available to treat type 2 diabetes (T2D) makes choosing the optimal drug for any given patient a complex task. Because newer agents offer several advantages, whether and when sulphonylureas (SUs) should still be used to treat T2D is controversial. Published treatment guidelines and recommendations should govern the general approach to diabetes management. However, expert opinions can aid in better understanding local practices and in formulating individual choices. The current consensus paper aims to provide additional guidance on the use of SUs in T2D. We summarize current local treatment guidelines in European countries, showing that SUs are still widely proposed as second-line treatment after metformin and are often ranked at the same level as newer glucose-lowering medications. Strong evidence now shows that sodium-glucose co-transporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are associated with low hypoglycaemia risk, promote weight loss, and exert a positive impact on vascular, cardiac and renal endpoints. Thus, using SUs in place of SGLT-2is and GLP-1RAs may deprive patients of key advantages and potentially important cardiorenal benefits. In subjects with ascertained cardiovascular disease or at very high cardiovascular risk, SGLT-2is and/or GLP-1RAs should be used as part of diabetes management, in the absence of contraindications. Routine utilization of SUs as second-line agents continues to be acceptable in resource-constrained settings.
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Affiliation(s)
| | - Leszek Czupryniak
- Department of Diabetology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Rui Duarte
- Associação Protectora dos Diabéticos de Portugal (APDP), Lisbon, Portugal
| | | | - Alexandra Kautzky-Willer
- Department of Internal Medicine III, Clinical Division of Endocrinology and Metabolism, Unit of Gender Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Miguel Melo
- Department of Endocrinology, Diabetes and Metabolism, University and Hospital Center of Coimbra, Coimbra, Portugal
- Medical Faculty, University of Coimbra, Coimbra, Portugal
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, The Faculty of Medicine, Jerusalem, Israel
| | | | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Gabriela Roman
- "Iuliu Hatieganu" University of Medicine & Pharmacy, Clinical Centre of Diabetes, Nutrition, Metabolic Diseases, Cluj-Napoca, Romania
| | - Oliver Schnell
- Forschergruppe Diabetes e.V., Helmholtz Centre, Munich, Germany
| | | | - Coen D A Stehouwer
- Department of Internal Medicine and Cardiovascular Research Institute (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Cees J Tack
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Vincent Woo
- Section of Endocrinology and Metabolism, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, The Faculty of Medicine, Jerusalem, Israel
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Phizackerley D. Making medicines safer? Drug Ther Bull 2020; 58:146. [PMID: 32855196 DOI: 10.1136/dtb.2020.000052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Schuemie MJ, Ryan PB, Pratt N, Chen R, You SC, Krumholz HM, Madigan D, Hripcsak G, Suchard MA. Principles of Large-scale Evidence Generation and Evaluation across a Network of Databases (LEGEND). J Am Med Inform Assoc 2020; 27:1331-1337. [PMID: 32909033 PMCID: PMC7481029 DOI: 10.1093/jamia/ocaa103] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/27/2020] [Accepted: 05/16/2020] [Indexed: 01/13/2023] Open
Abstract
Evidence derived from existing health-care data, such as administrative claims and electronic health records, can fill evidence gaps in medicine. However, many claim such data cannot be used to estimate causal treatment effects because of the potential for observational study bias; for example, due to residual confounding. Other concerns include P hacking and publication bias. In response, the Observational Health Data Sciences and Informatics international collaborative launched the Large-scale Evidence Generation and Evaluation across a Network of Databases (LEGEND) research initiative. Its mission is to generate evidence on the effects of medical interventions using observational health-care databases while addressing the aforementioned concerns by following a recently proposed paradigm. We define 10 principles of LEGEND that enshrine this new paradigm, prescribing the generation and dissemination of evidence on many research questions at once; for example, comparing all treatments for a disease for many outcomes, thus preventing publication bias. These questions are answered using a prespecified and systematic approach, avoiding P hacking. Best-practice statistical methods address measured confounding, and control questions (research questions where the answer is known) quantify potential residual bias. Finally, the evidence is generated in a network of databases to assess consistency by sharing open-source analytics code to enhance transparency and reproducibility, but without sharing patient-level information. Here we detail the LEGEND principles and provide a generic overview of a LEGEND study. Our companion paper highlights an example study on the effects of hypertension treatments, and evaluates the internal and external validity of the evidence we generate.
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Affiliation(s)
- Martijn J Schuemie
- Epidemiology Analytics, Janssen Research and Development, Titusville, New Jersey, USA
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Patrick B Ryan
- Epidemiology Analytics, Janssen Research and Development, Titusville, New Jersey, USA
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, Adelaide, South Australia, Australia
| | - RuiJun Chen
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Seng Chan You
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea
| | - Harlan M Krumholz
- Department of Medicine, Yale University School of Medicine, New Haven, California, USA
| | - David Madigan
- Department of Statistics, Columbia University, New York, New York, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA
- Medical Informatics Services, New York-Presbyterian Hospital, New York, New York, USA
| | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, California, USA
- Department of Biomathematics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California, USA
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Bowman L, Baras A, Bombien R, Califf RM, Chen Z, Gale CP, Gaziano JM, Grobbee DE, Maggioni AP, Muse ED, Roden DM, Schroeder S, Wallentin L, Casadei B. Understanding the use of observational and randomized data in cardiovascular medicine. Eur Heart J 2020; 41:2571-2578. [PMID: 32016367 DOI: 10.1093/eurheartj/ehaa020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/20/2019] [Accepted: 01/14/2020] [Indexed: 12/28/2022] Open
Abstract
The availability of large datasets from multiple sources [e.g. registries, biobanks, electronic health records (EHRs), claims or billing databases, implantable devices, wearable sensors, and mobile apps], coupled with advances in computing and analytic technologies, have provided new opportunities for conducting innovative health research. Equally, improved digital access to health information has facilitated the conduct of efficient randomized controlled trials (RCTs) upon which clinical management decisions can be based, for instance, by permitting the identification of eligible patients for recruitment and/or linkage for follow-up via their EHRs. Given these advances in cardiovascular data science and the complexities they behold, it is important that health professionals have clarity on the appropriate use and interpretation of observational, so-called 'real-world', and randomized data in cardiovascular medicine. The Cardiovascular Roundtable of the European Society of Cardiology (ESC) held a workshop to explore the future of RCTs and the current and emerging opportunities for gathering and exploiting complex observational datasets in cardiovascular research. The aim of this article is to provide a perspective on the appropriate use of randomized and observational data and to outline the ESC plans for supporting the collection and availability of clinical data to monitor and improve the quality of care of patients with cardiovascular disease in Europe and provide an infrastructure for undertaking pragmatic RCTs. Moreover, the ESC continues to campaign for greater engagement amongst regulators, industry, patients, and health professionals in the development and application of a more efficient regulatory framework that is able to take maximal advantage of new opportunities for improving the design and efficiency of observational studies and RCT in patients with cardiovascular disease.
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Affiliation(s)
- Louise Bowman
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Aris Baras
- Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | | | - Robert M Califf
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Zhengmin Chen
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - J Michael Gaziano
- Department of Medicine, VA Boston Healthcare System, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Diederick E Grobbee
- Department of Epidemiology, University Medical Center Utrecht, div. Julius Centrum, Utrech, The Netherlands
| | - Aldo P Maggioni
- EURObservational Research Programme, European Society of Cardiology, France
- ANMCO Research Center, Florence, Italy
| | - Evan D Muse
- Scripps Research Translational Institute, Scripps Clinic, La Jolla, San Diego, CA, USA
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Vanderbilt, Nashville, TN, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Vanderbilt, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Vanderbilt, Nashville, TN, USA
| | | | - Lars Wallentin
- Department of Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Barbara Casadei
- Radcliffe Department of Medicine, Division of Cardiovascular Medicine, Level 6, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Gerstein HC. Patient data from routinely collected medical records complement evidence from SGLT2 inhibitor outcome trials. Lancet Diabetes Endocrinol 2020; 8:557-558. [PMID: 32559467 DOI: 10.1016/s2213-8587(20)30187-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/05/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Hertzel C Gerstein
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8S 4K1, Canada.
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Longato E, Di Camillo B, Sparacino G, Gubian L, Avogaro A, Fadini GP. Cardiovascular outcomes of type 2 diabetic patients treated with SGLT-2 inhibitors versus GLP-1 receptor agonists in real-life. BMJ Open Diabetes Res Care 2020; 8:8/1/e001451. [PMID: 32591373 PMCID: PMC7319723 DOI: 10.1136/bmjdrc-2020-001451] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/12/2020] [Accepted: 05/24/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Sodium glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) protect type 2 diabetic (T2D) patients from cardiovascular events, but no trial has directly compared their cardiovascular effects. We aimed to address this gap using real-world data. RESEARCH DESIGN AND METHODS We performed a retrospective real-world study on a population of ~5 million inhabitants from North-East Italy. We identified T2D patients who received new prescription of SGLT2i or GLP-1RA from 2014 to 2018. SGLT2i and GLP-1RA initiators were matched 1:1 by propensity scores. The primary outcome was a composite of all-cause death, myocardial infarction, and stroke (three-point major adverse cardiovascular events (3P-MACE)). Secondary endpoints were each component of the primary endpoint, hospitalization for heart failure (HF), revascularization, hospitalization for cardiovascular causes, and adverse events. RESULTS From a population of 330 193 diabetic patients, we followed 8596 SGLT2i and GLP-1RA matched initiators for a median of 13 months. Patients in both groups were on average 63 years old, 63% men, and 18% had pre-existing cardiovascular disease. T2D patients treated with SGLT2i versus GLP-1RA, experienced a lower rate of 3P-MACE (HR 0.68; 95% CI 0.61 to 0.99; p=0.043), myocardial infarction (HR 0.72; 95% CI 0.53 to 0.98; p=0.035), hospitalization for HF (HR 0.59; 95% CI 0.35 to 0.99; p=0.048), and hospitalization for cardiovascular causes (HR 0.82; 95% CI 0.69 to 0.99; p=0.037). Adverse events were not significantly different between the two groups. CONCLUSIONS In the absence of dedicated trials, this observational study suggests that SGLT2i may be more effective than GLP-1RA in improving cardiovascular outcomes of T2D. TRIAL REGISTRATION NUMBER NCT04184947.
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Affiliation(s)
- Enrico Longato
- Department of Information Engineering, Università degli Studi di Padova, Padova, Veneto, Italy
| | - Barbara Di Camillo
- Department of Information Engineering, Università degli Studi di Padova, Padova, Veneto, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, Università degli Studi di Padova, Padova, Veneto, Italy
| | | | - Angelo Avogaro
- Department of Medicine, Università degli Studi di Padova, Padova, Veneto, Italy
| | - Gian Paolo Fadini
- Department of Medicine, Università degli Studi di Padova, Padova, Veneto, Italy
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Templeton AJ, Booth CM, Tannock IF. Informing Patients About Expected Outcomes: The Efficacy-Effectiveness Gap. J Clin Oncol 2020; 38:1651-1654. [DOI: 10.1200/jco.19.02035] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Arnoud J. Templeton
- Department of Medical Oncology, St Claraspital Basel, and Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Christopher M. Booth
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Ontario, Canada
| | - Ian F. Tannock
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Morieri ML, Rigato M, Frison V, Simioni N, D'Ambrosio M, Tadiotto F, Paccagnella A, Lapolla A, Avogaro A, Fadini GP. Effectiveness of dulaglutide vs liraglutide and exenatide once-weekly. A real-world study and meta-analysis of observational studies. Metabolism 2020; 106:154190. [PMID: 32109448 DOI: 10.1016/j.metabol.2020.154190] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/14/2020] [Accepted: 02/24/2020] [Indexed: 01/14/2023]
Abstract
INTRODUCTION AND AIM Real-word data on the head-to-head comparisons among glucagon-like peptide-1 receptor agonists (GLP-1RA) are scant. Therefore, we aimed to compare the effectiveness of dulaglutide versus liraglutide and exenatide once weekly (exeOW) in type 2 diabetic (T2D) patients under routine care. METHODS This was a retrospective, multicenter, real-world study on patients with T2D (aged 18-80) initiating a GLP-1RA between 2010 and 2018 at specialist outpatient clinics. We compared the effectiveness of dulaglutide versus liraglutide and exeOW on the changes in HbA1c (primary outcome), body weight, blood pressure and fasting glucose (secondary outcomes). Average follow-up was 5.9 months. Channelling biases were addressed with propensity score matching or multivariable adjustment. Meta-analyses of observational studies, covering the same comparisons, are also presented. RESULTS 849, 1371 and 198 patients were included in the dulaglutide, liraglutide and exeOW groups, respectively. The reduction of HbA1c was greater with dulaglutide than with liraglutide (-0.24 ± 0.08%; p = 0.003), and was confirmed in the meta-analysis of observational studies. In our study, dulaglutide showed similar effectiveness compared to exeOW. When these results were pooled with other observational studies, dulaglutide showed a greater reduction of HbA1c (-0.19%; p = 0.003) and body weight (-0.8 kg; p = 0.007). CONCLUSIONS In a real-world scenario, dulaglutide reduced HbA1c more than liraglutide. Conversely, we found similar effect of dulaglutide and exeOW, with statistical differences arising solely when results were meta-analysed with those from other observational studies. Lack of up-titration for liraglutide and higher discontinuation rate for exeOW likely influenced the estimated treatment difference.
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Affiliation(s)
- Mario Luca Morieri
- Department of Medicine, University of Padova, 35128 Padova, Italy; Division of Metabolic Diseases, Padova Hospital, 35128 Padova, Italy
| | | | - Vera Frison
- Internal Medicine and Diabetology Service, ULSS6, 35013 Cittadella, Italy
| | - Natalino Simioni
- Internal Medicine and Diabetology Service, ULSS6, 35013 Cittadella, Italy
| | | | | | | | - Annunziata Lapolla
- Department of Medicine, University of Padova, 35128 Padova, Italy; Diabetology Service ULSS6, 35100 Padova, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, 35128 Padova, Italy; Division of Metabolic Diseases, Padova Hospital, 35128 Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, 35128 Padova, Italy; Division of Metabolic Diseases, Padova Hospital, 35128 Padova, Italy.
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Sciannameo V, Berchialla P, Orsi E, Lamacchia O, Morano S, Querci F, Consoli A, Avogaro A, Fadini GP. Enrolment criteria for diabetes cardiovascular outcome trials do not inform on generalizability to clinical practice: The case of glucagon-like peptide-1 receptor agonists. Diabetes Obes Metab 2020; 22:817-827. [PMID: 31943710 DOI: 10.1111/dom.13962] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/26/2019] [Accepted: 01/08/2020] [Indexed: 02/06/2023]
Abstract
AIM To evaluate the generalizability of cardiovascular outcome trials (CVOTs) on glucagon-like peptide-1 receptor agonists (GLP-1RAs), we assessed what proportion of real-world patients with type 2 diabetes (T2D) constitute true CVOT-like populations. MATERIALS AND METHODS We applied inclusion/exclusion (I/E) criteria of each GLP-1RA CVOT to a cross-sectional database of 281 380 T2D patients from Italian diabetes outpatient clinics. We calculated the proportion of patients eligible for each CVOT and compared their clinical characteristics with those of trial patients. In addition, we used a Bayesian network-based method to sample the greatest subsets of real-world patients yielding true CVOT-like populations. RESULTS Between 98 725 and 124 164 T2D patients could be evaluated for CVOT eligibility. After excluding patients who were already on GLP-1RAs and applying I/E criteria, 35.8% of patients would be eligible for REWIND, 34.1% for PIONEER-6, 13.4% for EXSCEL, 10.1% for SUSTAIN-6, 9.5% for HARMONY and 9.4% for LEADER. Overall, 45.4% of patients could be eligible for at least one of the CVOTs. These patients, however, were extremely different to trial patients in most of the clinical characteristics, including demographics, concomitant medications and complications. The greatest CVOT-like subsets of real-world patients were 0.5% for SUSTAIN-6, 1.0% for EXSCEL, 1.2% for LEADER, 1.8% for PIONEER-6 and 7.9% for REWIND. CONCLUSIONS A very small proportion of real-world patients constitute true CVOT-like populations. These findings question whether any meaningful information can be drawn from applying trial enrolment criteria to real-world T2D patients.
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Affiliation(s)
- Veronica Sciannameo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Emanuela Orsi
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Olga Lamacchia
- Unit of Endocrinology, Department of Medical and Surgical Sciences, University Hospital of Foggia, Foggia, Italy
| | - Susanna Morano
- Unit of Diabetes Complications, V Clinica Medica, Department of Experimental Medicine, University of Rome "La Sapienza", Rome, Italy
| | - Fabrizio Querci
- Unit of Diabetology, ASST Bergamo Est, Alzano Lombardo, Italy
| | - Agostino Consoli
- Department of Medicine and Aging Science, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
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Kumar N, Ainooson J, Billings A, Chen G, Cueto L, Janmohamed K, Jiang J, Niaura R, Zhang A. The scope of tobacco cessation randomized controlled trials in low- to middle-income countries: protocol for a scoping review. Syst Rev 2020; 9:86. [PMID: 32317003 PMCID: PMC7171801 DOI: 10.1186/s13643-020-01361-2] [Citation(s) in RCA: 1] [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: 11/22/2019] [Accepted: 04/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Tobacco consumption is the leading cause of preventable death globally. The global mortality burden of tobacco use lies predominantly in low- to middle-income countries (LMICs). There is much evidence on the effectiveness of tobacco cessation RCTs in high-income nations. However, the evidence base in LMICs is far more limited. To effectively design randomized controlled trials (RCTs) that mitigate tobacco-related harms in LMICs, further understanding of RCTs in this environment will be helpful. We will provide quality evidence regarding the scope of tobacco cessation RCTs in LMICs. METHODS A scoping review of tobacco cessation RCTs will be conducted. MEDLINE, Embase, PsycINFO, Global Health, Web of Science and Sociological Abstracts will be searched to capture current literature. We will review RCTs that have already been done on tobacco cessation in the LMICs. The key outcome will be tobacco cessation in adults. Examples of the key outcome include smoking abstinence and reduction of tobacco use. Study selection will conform to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines and study quality assessed with a modified version of the Cochrane Collaboration's instrument. DISCUSSION As researchers attempt to minimize the harms from tobacco in LMICs, they need to be aware of scientific evidence to develop RCTs to achieve their aim. The review will complement the evidence base on tobacco cessation in LMICs.
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Affiliation(s)
- Navin Kumar
- Human Nature Lab, Department of Sociology, Yale University, New Haven, CT, USA.
| | - Jessica Ainooson
- Human Nature Lab, Department of Sociology, Yale University, New Haven, CT, USA
| | - Ameera Billings
- Human Nature Lab, Department of Sociology, Yale University, New Haven, CT, USA
| | - Grace Chen
- Human Nature Lab, Department of Sociology, Yale University, New Haven, CT, USA
| | - Lauren Cueto
- Human Nature Lab, Department of Sociology, Yale University, New Haven, CT, USA
| | - Kamila Janmohamed
- Human Nature Lab, Department of Sociology, Yale University, New Haven, CT, USA
| | - Jeannette Jiang
- Human Nature Lab, Department of Sociology, Yale University, New Haven, CT, USA
| | - Raymond Niaura
- Department of Social and Behavioral Sciences, College of Global Public Health, New York University, 715 Broadway, New York, NY, USA.,Department of Epidemiology, College of Global Public Health, New York University, 715 Broadway, New York, NY, USA
| | - Amy Zhang
- Human Nature Lab, Department of Sociology, Yale University, New Haven, CT, USA
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49
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Ganz T, Aronoff GR, Gaillard CAJM, Goodnough LT, Macdougall IC, Mayer G, Porto G, Winkelmayer WC, Wish JB. Iron Administration, Infection, and Anemia Management in CKD: Untangling the Effects of Intravenous Iron Therapy on Immunity and Infection Risk. Kidney Med 2020; 2:341-353. [PMID: 32734254 PMCID: PMC7380433 DOI: 10.1016/j.xkme.2020.01.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Patients with chronic kidney disease (CKD) are at increased risk for infection, attributable to immune dysfunction, increased exposure to infectious agents, loss of cutaneous barriers, comorbid conditions, and treatment-related factors (eg, hemodialysis and immunosuppressant therapy). Because iron plays a vital role in pathogen reproduction and host immunity, it is biologically plausible that intravenous iron therapy and/or iron deficiency influence infection risk in CKD. Available data from preclinical experiments, observational studies, and randomized controlled trials are summarized to explore the interplay between intravenous iron and infection risk among patients with CKD, particularly those receiving maintenance hemodialysis. The current evidence base, including data from a recent randomized controlled trial, suggests that proactive judicious use of intravenous iron (in a manner that minimizes the accumulation of non-transferrin-bound iron) beneficially replaces iron stores while avoiding a clinically relevant effect on infection risk. In the absence of an urgent clinical need, intravenous iron therapy should be avoided in patients with active infection. Although serum ferritin concentration and transferrin saturation can help guide clinical decision making about intravenous iron therapy, definition of an optimal iron status and its precise determination in individual patients remain clinically challenging in CKD and warrant additional study.
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Affiliation(s)
- Tomas Ganz
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | | | | | - Lawrence T Goodnough
- Department of Pathology, Stanford University, Stanford, CA.,Department of Medicine (Hematology), Stanford University, Stanford, CA
| | - Iain C Macdougall
- Department of Renal Medicine, King's College Hospital, London, United Kingdom
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Graça Porto
- Pathology and Molecular Immunology Department, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal.,i3S, Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Jay B Wish
- Division of Nephrology, Indiana University Health, Indianapolis, IN
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50
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Cortes J, Perez-García JM, Llombart-Cussac A, Curigliano G, El Saghir NS, Cardoso F, Barrios CH, Wagle S, Roman J, Harbeck N, Eniu A, Kaufman PA, Tabernero J, García-Estévez L, Schmid P, Arribas J. Enhancing global access to cancer medicines. CA Cancer J Clin 2020; 70:105-124. [PMID: 32068901 DOI: 10.3322/caac.21597] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Globally, cancer is the second leading cause of death, with numbers greatly exceeding those for human immunodeficiency virus/acquired immunodeficiency syndrome, tuberculosis, and malaria combined. Limited access to timely diagnosis, to affordable, effective treatment, and to high-quality care are just some of the factors that lead to disparities in cancer survival between countries and within countries. In this article, the authors consider various factors that prevent access to cancer medicines (particularly access to essential cancer medicines). Even if an essential cancer medicine is included on a national medicines list, cost might preclude its use, it might be prescribed or used inappropriately, weak infrastructure might prevent it being accessed by those who could benefit, or quality might not be guaranteed. Potential strategies to address the access problems are discussed, including universal health coverage for essential cancer medicines, fairer methods for pricing cancer medicines, reducing development costs, optimizing regulation, and improving reliability in the global supply chain. Optimizing schedules for cancer therapy could reduce not only costs, but also adverse events, and improve access. More and better biomarkers are required to target patients who are most likely to benefit from cancer medicines. The optimum use of cancer medicines depends on the effective delivery of several services allied to oncology (including laboratory, imaging, surgery, and radiotherapy). Investment is necessary in all aspects of cancer care, from these supportive services to technologies, and the training of health care workers and other staff.
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Affiliation(s)
- Javier Cortes
- IOB Institute of Oncology, Quironsalud Group, Madrid, Spain
- IOB Institute of Oncology, Quironsalud Group, Hospital Quiron, Barcelona, Spain
- Medica Scientia Innovation Research, Barcelona, Spain
- Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Jose Manuel Perez-García
- IOB Institute of Oncology, Quironsalud Group, Hospital Quiron, Barcelona, Spain
- Medica Scientia Innovation Research, Barcelona, Spain
| | | | | | - Nagi S El Saghir
- Division of Hematology Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Carlos H Barrios
- Oncology Research Center, Hospital Sao Lucas, Porto Alegre, Brazil
| | | | - Javier Roman
- Breast Unit, Gastrointestinal Tumor Unit and Lung Tumor Unit, IOB Institute of Oncology, Quironsalud Group, Madrid, Spain
| | - Nadia Harbeck
- Breast Center, Department of Obstetrics and Gynecology, University of Munich (LMU), Munich, Germany
| | | | | | - Josep Tabernero
- IOB Institute of Oncology, Quironsalud Group, Hospital Quiron, Barcelona, Spain
- Medical Oncology Department, Vall d'Hebron Institute of Oncology, CIBERONC, Barcelona, Spain
| | | | - Peter Schmid
- Center of Experimental Cancer Medicine, Barts Cancer Institute, St. Bartholomew Breast Cancer Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Joaquín Arribas
- Preclinical Research Program, Vall d'Hebron Institute of Oncology, Barcelona, Spain
- Biomedical Research Oncology Network (CIBERONC), Barcelona, Spain
- Department of Biochemistry and Molecular Biology, Autonomous University of Barcelona, Bellaterra, Spain
- Catalan Institution for Research and Advanced Studies, (ICREA), Barcelona, Spain
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