Long term extension of a randomised controlled trial of probiotics using electronic health records

Leveraging Real-World Evidence and Observational Studies in Treating Multiple Sclerosis

Randomized controlled trials (RCTs) are essential for regulatory approval of disease-modifying therapies (DMTs), yet their strict selection criteria often lead to limited generalizability. Observational studies using real-world data (RWD) allow for more inclusive heterogeneous cohorts resulting in higher external validity to inform treatment practices. As reviewed in this article, well-designed comparative effectiveness studies are an important application of RWD. Although, like RCTs, observational studies have their own set of limitations, including various biases that may confound results, advanced statistical methods can mitigate many of these limitations. A focus on personalized treatment will continue to add value to individualize MS care.

Trends in socioeconomic inequalities in incidence of severe mental illness - A population-based linkage study using primary and secondary care routinely collected data between 2000 and 2017

OBJECTIVE

In 2008, the UK entered a period of economic recession followed by sustained austerity measures. We investigate changes in inequalities by area deprivation and urbanicity in incidence of severe mental illness (SMI, including schizophrenia-related disorders and bipolar disorder) between 2000 and 2017.

METHODS

We analysed 4.4 million individuals from primary and secondary care routinely collected datasets (2000-2017) in Wales and estimated the incidence of SMI by deprivation and urbanicity measured by the Welsh Index of Multiple Deprivation (WIMD) and urban/rural indicator respectively. Using linear modelling and joinpoint regression approaches, we examined time trends of the incidence and incidence rate ratios (IRR) of SMI by the WIMD and urban/rural indicator adjusted for available confounders.

RESULTS

We observed a turning point of time trends of incidence of SMI at 2008/2009 where slope changes of time trends were significantly increasing. IRRs by deprivation/urbanicity remained stable or significantly decreased over the study period except for those with bipolar disorder sourced from secondary care settings, with increasing trend of IRRs (increase in IRR by deprivation after 2010: 1.6 % per year, 95 % CI: 1.0 %-2.2 %; increase in IRR by urbanicity 1.0 % per year, 95 % CI: 0.6 %-1.3 %).

CONCLUSIONS

There was an association between recession/austerity and an increase in the incidence of SMI over time. There were variations in the effects of deprivation/urbanicity on incidence of SMI associated with short- and long-term socioeconomic change. These findings may support targeted interventions and social protection systems to reduce incidence of SMI.

Using probiotics in paediatric populations

This statement defines probiotics and reviews the most recent literature on their use in paediatrics. Many studies have examined the potential benefit of probiotics, but significant variation in the strains and doses of probiotics used, the patient populations studied, and in study design, have led to heterogeneous results. Present evidence suggests that probiotics can decrease mortality and lower incidence of necrotizing enterocolitis in preterm and low birth weight neonates. Probiotics may also be beneficial in reducing feeding intolerance. In infants, probiotics may be considered to reduce symptoms of colic. In older children, probiotics can be considered to prevent antibiotic-associated diarrhea and Clostridium difficile -associated diarrhea. Probiotic supplements used in conjunction with standard therapy can help with Helicobacter pylori eradication and decrease the side effects of treatment. Lactobacillus species can be considered to treat irritable bowel syndrome. Probiotics can also be considered to help prevent atopic dermatitis and eczema. To optimize paediatric policy and practice, large, quality studies are needed to determine what types and combinations of probiotics are most efficacious.

L’utilisation des probiotiques dans la population pédiatrique

Le présent document de principes définit les probiotiques et fournit une analyse des publications scientifiques les plus récentes sur leur utilisation en pédiatrie. De nombreuses études ont évalué les avantages potentiels des probiotiques, mais en raison des variations importantes dans les souches et les doses utilisées, des populations de patients étudiées et des méthodologies privilégiées, les résultats sont hétérogènes. Selon les données probantes à jour, les probiotiques peuvent réduire le taux de mortalité et l’incidence d’entérocolite nécrosante chez les nouveau-nés prématurés et de petit poids à la naissance. Ils peuvent également être bénéfiques pour réduire l’intolérance alimentaire. Chez les nourrissons, on peut envisager de les utiliser pour limiter les symptômes de coliques, et chez les enfants plus âgés, pour prévenir la diarrhée associée aux antibiotiques ou au Clostridium difficile . Les suppléments de probiotiques utilisés conjointement avec un traitement standard peuvent contribuer à éradiquer l’Helicobacter pylori et à atténuer les effets secondaires du traitement. On peut envisager d’utiliser des espèces de Lactobacillus pour traiter le syndrome du côlon irritable ou de recourir à des probiotiques pour contribuer à prévenir la dermatite atopique et l’eczéma. Afin d’optimiser les politiques et les pratiques en pédiatrie, de vastes études de qualité devront être réalisées pour déterminer les types et les combinaisons de probiotiques les plus efficaces.

Periodontal Regenerative Therapy Using rhFGF-2 and Deproteinized Bovine Bone Mineral versus rhFGF-2 Alone: 4-Year Extended Follow-Up of a Randomized Controlled Trial

The aim of this study was to evaluate longitudinal outcomes of recombinant human fibroblast growth factor (rhFGF)-2 plus deproteinized bovine bone mineral (DBBM) therapy in comparison with rhFGF-2 alone for treating periodontal intrabony defects. This study describes 4-year follow-up outcomes of the original randomized controlled trial. Intrabony defects in periodontitis patients were treated with rhFGF-2 (control) or rhFGF-2 plus DBBM (test). Clinical, radiographic, and patient-reported outcome (PRO) measures were used to evaluate the outcomes. Thirty-two sites were able to be followed up. At 4 years postoperatively, clinical attachment level (CAL) gains in the test and control groups were 3.5 ± 1.4 mm and 2.7 ± 1.4 mm, respectively, showing significant improvement from preoperative values but no difference between groups. Both groups showed an increase in radiographic bone fill (RBF) over time. At 4 years, the mean value for RBF in the test group (62%) was significantly greater than that in the control group (42%). In 1-2-wall defects, the test treatment yielded significantly greater RBF than the control treatment. No significant difference in PRO scores was noted between the groups. Although no significant difference in CAL gain was found between the groups at the 4-year follow-up, the combination treatment significantly enhanced RBF. Favorable clinical, radiographic outcomes, and PRO in both groups can be maintained for at least 4 years.

Respiratory and Intestinal Microbiota in Pediatric Lung Diseases-Current Evidence of the Gut-Lung Axis

The intestinal microbiota is known to influence local immune homeostasis in the gut and to shape the developing immune system towards elimination of pathogens and tolerance towards self-antigens. Even though the lung was considered sterile for a long time, recent evidence using next-generation sequencing techniques confirmed that the lower airways possess their own local microbiota. Since then, there has been growing evidence that the local respiratory and intestinal microbiota play a role in acute and chronic pediatric lung diseases. The concept of the so-called gut–lung axis describing the mutual influence of local microbiota on distal immune mechanisms was established. The mechanisms by which the intestinal microbiota modulates the systemic immune response include the production of short-chain fatty acids (SCFA) and signaling through pattern recognition receptors (PRR) and segmented filamentous bacteria. Those factors influence the secretion of pro- and anti-inflammatory cytokines by immune cells and further modulate differentiation and recruitment of T cells to the lung. This article does not only aim at reviewing recent mechanistic evidence from animal studies regarding the gut–lung axis, but also summarizes current knowledge from observational studies and human trials investigating the role of the respiratory and intestinal microbiota and their modulation by pre-, pro-, and synbiotics in pediatric lung diseases.

Maternal Intake of Probiotics to Program Offspring Health

PURPOSE OF REVIEW

Probiotics intake may be considered beneficial by prospective and pregnant mothers, but their effects on offspring development are incompletely understood. The purpose of this review was to examine recent pre-clinical and clinical studies to understand how maternal probiotics exposure affects offspring health outcomes.

RECENT FINDINGS

Effects were investigated in the context of supporting offspring growth, intestinal health, and gut microbiota, preventing allergic diseases, supporting neurodevelopment, and preventing metabolic disorders in pre-clinical and clinical studies. Most human studies focused on infancy outcomes, whereas pre-clinical studies also examined outcomes at adolescence and young adulthood. While still understudied, both pre-clinical and clinical studies propose epigenetic modifications as an underlying mechanism. Optimal timing of intervention remains unclear. Administration of selected probiotics to mothers has programming potential for sustaining life-long health of offspring. Administration protocols, specific windows of susceptibility, and individual-specific responses need to be further studied.

Comparative effectiveness of probiotic strains on the prevention of pediatric atopic dermatitis: A systematic review and network meta-analysis

BACKGROUND

Atopic dermatitis is the most common chronic skin disease affecting the pediatric population. Probiotics have been proposed to be effective in preventing the development of pediatric atopic dermatitis. Although studies show promise for the use of probiotics, the evidence is still inconclusive due to significant heterogeneity and imprecision.

OBJECTIVE

To determine the comparative effectiveness of the different types of probiotic strains in preventing the development of atopic dermatitis among pediatric patients.

METHODOLOGY

A systematic search of Cochrane Library, MEDLINE, TRIP Database, and Centre for Research and Dissemination was conducted. Manual search of the reference lists and search for unpublished articles were also done. All randomized controlled trials available from inception until April 12, 2020, on the use of probiotics in the prevention of atopic dermatitis among children were included. The comparator groups considered are other probiotic strains and placebo. The primary outcome of interest was the development of atopic dermatitis. Two authors independently searched for articles, screened the articles for inclusion, appraised the articles using the Cochrane risk of bias tool version 2, and extracted the data. In case of disagreement, the two authors discussed the source of disagreement until consensus was reached. If consensus was not reached, an independent third party reviewer was consulted. Frequentist network meta-analysis was conducted using STATA 14 software. The ranking probabilities and surface under the cumulative ranking curve (SUCRA) values were obtained to determine ranking of the different probiotic strains based on efficacy and safety data.

RESULTS

We included 21 original studies represented by 35 records and a total of 5406 children with atopic dermatitis as diagnosed by clinicians or fulfillment of validated diagnostic criteria. All studies were randomized placebo-controlled trials. The top 3 probiotic preparations in terms of efficacy in reducing the risk of atopic dermatitis are Mix8 (Lactobacillus paracasei ST11, Bifidobacterium longum BL999), LP (Lactobacillus paracasei ssp paracasei F19) and Mix3 (Lactobacillus rhamnosus GG, Bifidobacterium animalis ssp lactis Bb-12). Mix8 compared with placebo probably reduces the risk of atopic dermatitis based on low-quality evidence (RR = 0.46, 95% CI 0.25-0.85). Mix3 compared with placebo also probably reduces the risk of atopic dermatitis based on low-quality evidence (RR = 0.50, 95% CI 0.27-0.94). It is uncertain whether LP compared with placebo reduces the risk of atopic dermatitis due to very-low-quality certainty of evidence (RR = 0.49, 95% CI 0.20-1.19). In terms of adverse events, LGG may slightly lead to less adverse events compared with placebo based on low-quality evidence (RR = 0.70, 95% CI 0.32-1.52). Mix4 may slightly lead to more adverse events compared with placebo based on low-quality evidence (RR = 1.06, 95% CI 0.02-51.88). Based on subgroup analysis of studies involving infants, Mix3 compared with placebo probably reduces the risk of atopic dermatitis based on low-quality evidence (RR = 0.46, 95% CI 0.22-0.97). In the subgroup analysis of studies where probiotics were administered to pregnant women and to infants, LRH compared with placebo probably reduces the risk of atopic dermatitis based on moderate-quality evidence (RR = 0.54, 95% CI 0.26-1.11).

CONCLUSION

Certain probiotic preparations demonstrate efficacy in reducing the risk of developing atopic dermatitis when administered to pregnant women, infants, or both.

Prevention and Management with Pro-, Pre and Synbiotics in Children with Asthma and Allergic Rhinitis: A Narrative Review

Allergic diseases including allergic rhinitis and asthma are increasing in the developing world, related to a westernizing lifestyle, while the prevalence is stable and decreasing in the industrialized world. This paper aims to answer the question if prevention and/or treatment of allergic rhinitis and asthma can be achieved by administrating pro-, pre- and/or synbiotics that might contribute to stabilizing the disturbed microbiome that influences the immune system through the gut-lung axis. We searched for relevant English articles in PubMed and Google Scholar. Articles interesting for the topic were selected using subject heading and key words. Interesting references in included articles were also considered. While there is substantial evidence from animal studies in well controlled conditions that selected probiotic strains may offer benefits in the prevention of wheezing and asthma, outcomes from clinical studies in infants (including as well pre- and postnatal administration) are disappointing. The latter may be related to the multiple confounding factors such as environment, strain selection and dosage, moment of administration and genetic background. There is little evidence to recommend administration of pro, pre- or synbiotics in the prevention of asthma and allergic rhinitis in children.

Using electronic patient records to assess the effect of a complex antenatal intervention in a cluster randomised controlled trial-data management experience from the DESiGN Trial team

BACKGROUND

The use of electronic patient records for assessing outcomes in clinical trials is a methodological strategy intended to drive faster and more cost-efficient acquisition of results. The aim of this manuscript was to outline the data collection and management considerations of a maternity and perinatal clinical trial using data from electronic patient records, exemplifying the DESiGN Trial as a case study.

METHODS

The DESiGN Trial is a cluster randomised control trial assessing the effect of a complex intervention versus standard care for identifying small for gestational age foetuses. Data on maternal/perinatal characteristics and outcomes including infants admitted to neonatal care, parameters from foetal ultrasound and details of hospital activity for health-economic evaluation were collected at two time points from four types of electronic patient records held in 22 different electronic record systems at the 13 research clusters. Data were pseudonymised on site using a bespoke Microsoft Excel macro and securely transferred to the central data store. Data quality checks were undertaken. Rules for data harmonisation of the raw data were developed and a data dictionary produced, along with rules and assumptions for data linkage of the datasets. The dictionary included descriptions of the rationale and assumptions for data harmonisation and quality checks.

RESULTS

Data were collected on 182,052 babies from 178,350 pregnancies in 165,397 unique women. Data availability and completeness varied across research sites; each of eight variables which were key to calculation of the primary outcome were completely missing in median 3 (range 1-4) clusters at the time of the first data download. This improved by the second data download following clarification of instructions to the research sites (each of the eight key variables were completely missing in median 1 (range 0-1) cluster at the second time point). Common data management challenges were harmonising a single variable from multiple sources and categorising free-text data, solutions were developed for this trial.

CONCLUSIONS

Conduct of clinical trials which use electronic patient records for the assessment of outcomes can be time and cost-effective but still requires appropriate time and resources to maximise data quality. A difficulty for pregnancy and perinatal research in the UK is the wide variety of different systems used to collect patient data across maternity units. In this manuscript, we describe how we managed this and provide a detailed data dictionary covering the harmonisation of variable names and values that will be helpful for other researchers working with these data.

TRIAL REGISTRATION

Primary registry and trial identifying number: ISRCTN 67698474 . Registered on 02/11/16.

Periodontal surgery using rhFGF-2 with deproteinized bovine bone mineral or rhFGF-2 alone: 2-year follow-up of a randomized controlled trial

AIM

To compare outcomes of rhFGF-2 + DBBM therapy with rhFGF-2 alone in the treatment of intrabony defects. This study provides 2-year follow-up results from the previous randomized controlled trial.

MATERIALS AND METHODS

Defects were randomly allocated to receive rhFGF-2 + DBBM (test) or rhFGF-2 (control). Treated sites were re-evaluated at 2 years postoperatively, using original clinical and patient-centred measures.

RESULTS

Thirty-eight sites were available for re-evaluation. At 2 years, both groups showed a significant improvement in clinical attachment level (CAL) from baseline. A gain in CAL of 3.4 ± 1.3 mm in the test group and 3.1 ± 1.5 mm in the control group was found. No significant inter-group difference was noted. Both groups showed a progressive increase in radiographic bone fill (RBF). The test treatment yielded greater RBF (56%) compared with the control group (41%). The control treatment performed better in contained defects in terms of CAL and RBF. There was no significant difference in patient-reported outcomes between groups.

CONCLUSIONS

At 2-year follow-up, the test and cotrol treatments were similarly effective in improving CAL, whereas the test treatment achieved a significantly greater RBF. In both treatments, favourable clinical, radiographic, and patient-reported outcomes can be sustained for at least 2 years.

TRIAL REGISTRATION

The University Hospital Medical Information Network-Clinical Trials Registry (UMIN-CTR) 000025257.

The Gut Microbiota and Respiratory Diseases: New Evidence

Human body surfaces, such as the skin, intestines, and respiratory and urogenital tracts, are colonized by a large number of microorganisms, including bacteria, fungi, and viruses, with the gut being the most densely and extensively colonized organ. The microbiome plays an essential role in immune system development and tissue homeostasis. Gut microbiota dysbiosis not only modulates the immune responses of the gastrointestinal (GI) tract but also impacts the immunity of distal organs, such as the lung, further affecting lung health and respiratory diseases. Here, we review the recent evidence of the correlations and underlying mechanisms of the relationship between the gut microbiota and common respiratory diseases, including asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), lung cancer, and respiratory infection, and probiotic development as a therapeutic intervention for these diseases.

Probiotic Supplementation During the Perinatal and Infant Period: Effects on Gut Dysbiosis and Disease

The perinatal period is crucial to the establishment of lifelong gut microbiota. The abundance and composition of microbiota can be altered by several factors such as preterm delivery, formula feeding, infections, antibiotic treatment, and lifestyle during pregnancy. Gut dysbiosis affects the development of innate and adaptive immune responses and resistance to pathogens, promoting atopic diseases, food sensitization, and infections such as necrotizing enterocolitis (NEC). Recent studies have indicated that the gut microbiota imbalance can be restored after a single or multi-strain probiotic supplementation, especially mixtures of Lactobacillus and Bifidobacterium strains. Following the systematic search methodology, the current review addresses the importance of probiotics as a preventive or therapeutic tool for dysbiosis produced during the perinatal and infant period. We also discuss the safety of the use of probiotics in pregnant women, preterm neonates, or infants for the treatment of atopic diseases and infections.

Area deprivation, urbanicity, severe mental illness and social drift - A population-based linkage study using routinely collected primary and secondary care data

We investigated whether associations between area deprivation, urbanicity and elevated risk of severe mental illnesses (SMIs, including schizophrenia and bipolar disorder) is accounted for by social drift or social causation. We extracted primary and secondary care electronic health records from 2004 to 2015 from a population of 3.9 million. We identified prevalent and incident individuals with SMIs and their level of deprivation and urbanicity using the Welsh Index of Multiple Deprivation (WIMD) and urban/rural indicator. The presence of social drift was determined by whether odds ratios (ORs) from logistic regression is greater than the incidence rate ratios (IRRs) from Poisson regression. Additionally, we performed longitudinal analysis to measure the proportion of change in deprivation level and rural/urban residence 10 years after an incident diagnosis of SMI and compared it to the general population using standardised rate ratios (SRRs). Prevalence and incidence of SMIs were significantly associated with deprivation and urbanicity (all ORs and IRRs significantly >1). ORs and IRRs were similar across all conditions and cohorts (ranging from 1.1 to 1.4). Results from the longitudinal analysis showed individuals with SMIs are more likely to move compared to the general population. However, they did not preferentially move to more deprived or urban areas. There was little evidence of downward social drift over a 10-year period. These findings have implications for the allocation of resources, service configuration and access to services in deprived communities, as well as, for broader public health interventions addressing poverty, and social and environmental contexts.

Using general practice clinical information system data for research: the case in Australia

General practice is often a patient’s first point of contact with the health system and the gateway to specialist services. In Australia, different aspects of the health system are managed by the Commonwealth Government and individual state / territory governments. Although there is a long history of research using administrative data in Australia, this split in the management and funding of services has hindered whole-system research. Additionally, the administrative data typically available for research are often collected for reimbursement purposes and lack clinical information.

General practices collect a range of patient information including diagnoses, medications prescribed, results of pathology tests ordered and so on. Practices are increasingly using clinical information systems and data extraction tools to make use of this information. This paper describes approaches used on several research projects to access clinical, as opposed to administrative, general practice data which to date has seen little use as a resource for research.

This information was accessed in three ways. The first was by working directly with practices to access clinical and management data to support research. The second involved accessing general practice data through collaboration with Primary Health Networks, recently established in Australia to increase the efficiency and effectiveness of health services for patients. The third was via NPS MedicineWise’s MedicineInsight program, which collects data from consenting practices across Australia and makes these data available to researchers.

We describe each approach including data access requirements and the advantages and challenges of each method. All approaches provide the opportunity to better understand data previously unavailable for research in Australia. The challenge of linking general practice data to other sources, currently being explored for general practice data, is discussed.

Finally, we describe some general practice data collections used for research internationally and how these compare to collections available in Australia.

The Human Microbiota and Asthma

Over the last few decades, advances in our understanding of microbial ecology have allowed us to appreciate the important role of microbial communities in maintaining human health. While much of this research has focused on gut microbes, microbial communities in other body sites and from the environment are increasingly recognized in human disease. Here, we discuss recent advances in our understanding of host-microbiota interactions in the development and manifestation of asthma focusing on three distinct microbial compartments. First, environmental microbes originating from house dust, pets, and farm animals have been linked to asthma pathogenesis, which is often connected to their production of bioactive molecules such as lipopolysaccharide. Second, respiratory microbial communities, including newly appreciated populations of microbes in the lung have been associated with allergic airway inflammation. Current evidence suggests that the presence of particular microbes, especially Streptococcus, Haemophilus, and Morexella species within the airway may shape local immune responses and alter the severity and manifestations of airway inflammation. Third, the gut microbiota has been implicated in both experimental models and clinical studies in predisposing to asthma. There appears to be a "critical window" of colonization that occurs during early infancy in which gut microbial communities shape immune maturation and confer susceptibility to allergic airway inflammation. The mechanisms by which gut microbial communities influence lung immune responses and physiology, the "gut-lung axis," are still being defined but include the altered differentiation of immune cell populations important in asthma and the local production of metabolites that affect distal sites. Together, these findings suggest an intimate association of microbial communities with host immune development and the development of allergic airway inflammation. Improved understanding of these relationships raises the possibility of microbiota-directed therapies to improve or prevent asthma.

Effect of pedometer-based walking interventions on long-term health outcomes: Prospective 4-year follow-up of two randomised controlled trials using routine primary care data

BACKGROUND

Data are lacking from physical activity (PA) trials with long-term follow-up of both objectively measured PA levels and robust health outcomes. Two primary care 12-week pedometer-based walking interventions in adults and older adults (PACE-UP and PACE-Lift) found sustained objectively measured PA increases at 3 and 4 years, respectively. We aimed to evaluate trial intervention effects on long-term health outcomes relevant to walking interventions, using routine primary care data.

METHODS AND FINDINGS

Randomisation was from October 2012 to November 2013 for PACE-UP participants from seven general (family) practices and October 2011 to October 2012 for PACE-Lift participants from three practices. We downloaded primary care data, masked to intervention or control status, for 1,001 PACE-UP participants aged 45-75 years, 36% (361) male, and 296 PACE-Lift participants, aged 60-75 years, 46% (138) male, who gave written informed consent, for 4-year periods following randomisation. The following new events were counted for all participants, including those with preexisting diseases (apart from diabetes, for which existing cases were excluded): nonfatal cardiovascular, total cardiovascular (including fatal), incident diabetes, depression, fractures, and falls. Intervention effects on time to first event post-randomisation were modelled using Cox regression for all outcomes, except for falls, which used negative binomial regression to allow for multiple events, adjusting for age, sex, and study. Absolute risk reductions (ARRs) and numbers needed to treat (NNTs) were estimated. Data were downloaded for 1,297 (98%) of 1,321 trial participants. Event rates were low (<20 per group) for outcomes, apart from fractures and falls. Cox hazard ratios for time to first event post-randomisation for interventions versus controls were nonfatal cardiovascular 0.24 (95% confidence interval [CI] 0.07-0.77, p = 0.02), total cardiovascular 0.34 (95% CI 0.12-0.91, p = 0.03), diabetes 0.75 (95% CI 0.42-1.36, p = 0.34), depression 0.98 (95% CI 0.46-2.07, p = 0.96), and fractures 0.56 (95% CI 0.35-0.90, p = 0.02). Negative binomial incident rate ratio for falls was 1.07 (95% CI 0.78-1.46, p = 0.67). ARR and NNT for cardiovascular events were nonfatal 1.7% (95% CI 0.5%-2.1%), NNT = 59 (95% CI 48-194); total 1.6% (95% CI 0.2%-2.2%), NNT = 61 (95% CI 46-472); and for fractures 3.6% (95% CI 0.8%-5.4%), NNT = 28 (95% CI 19-125). Main limitations were that event rates were low and only events recorded in primary care records were counted; however, any underrecording would not have differed by intervention status and so should not have led to bias.

CONCLUSIONS

Routine primary care data used to assess long-term trial outcomes demonstrated significantly fewer new cardiovascular events and fractures in intervention participants at 4 years. No statistically significant differences between intervention and control groups were demonstrated for other events. Short-term primary care pedometer-based walking interventions can produce long-term health benefits and should be more widely used to help address the public health inactivity challenge.

TRIAL REGISTRATIONS

PACE-UP isrctn.com ISRCTN98538934; PACE-Lift isrctn.com ISRCTN42122561.