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Overvad TF, Severinsen MT, Johnsen SP, Madsen SS, Kannik K, Stenfeldt LG, Larsen TB, Nielsen PB. Positive predictive value and sensitivity of cancer-associated venous thromboembolism diagnoses in the Danish National Patient Register. Thromb Res 2024; 241:109074. [PMID: 38959580 DOI: 10.1016/j.thromres.2024.109074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 06/17/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Hospital discharge diagnoses from administrative registries are frequently used in studies of cancer-associated venous thromboembolism, but the validity of International Classification of Diseases (ICD) codes for identifying such events is unknown. MATERIALS AND METHODS Using patient samples from the Danish National Patient Register, we calculated positive predictive values (PPV), i.e., the proportion of registered ICD codes, which could be confirmed after manual search of the electronic health record. Sensitivity was estimated in a sample of patients with imaging-verified venous thromboembolism but without prior knowledge about their ICD coding status. Sensitivity was calculated as the proportion of these patients, who were discharged with an ICD code for venous thromboembolism. RESULTS The overall PPV of an ICD-10 diagnosis of cancer-associated venous thromboembolism was 75.9 % (95 % confidence interval 71.3-80.0). In subgroups, the PPV was particularly low for recurrent venous thromboembolism (44.2 %), diagnoses in a secondary position (55.7 %), outpatient diagnoses (65.3 %), and diagnoses given at surgical (66.7 %), emergency wards (48.4 %), or via hospices/palliative teams (0 %). The overall sensitivity was 68 %, meaning 32 % of patients with cancer diagnosed in hospital with venous thromboembolism were discharged without any registered ICD code for venous thromboembolism. CONCLUSIONS The positive predictive value of an ICD diagnosis of cancer-associated venous thromboembolism in the Danish Patient Register was overall adequate for research purposes, but with notable variation across subgroups. Sensitivity was limited, as 1/3 of patients with venous thromboembolism were discharged without any relevant ICD code. Cautious interpretation of incidence of cancer-associated venous thromboembolism based on administrative register-based data is warranted.
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Affiliation(s)
- Thure Filskov Overvad
- Department of Clinical Pharmacology, Aalborg University Hospital, Denmark; Department of Clinical Pharmacology, Aarhus University Hospital, Denmark.
| | - Marianne Tang Severinsen
- Department of Hematology, Clinical Cancer Research Unit, Aalborg University Hospital, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Karina Kannik
- Department of Hematology, Clinical Cancer Research Unit, Aalborg University Hospital, Denmark
| | | | | | - Peter Brønnum Nielsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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2
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Zuin M, Henkin S, Harder EM, Piazza G. Optimal hemodynamic parameters for risk stratification in acute pulmonary embolism patients. J Thromb Thrombolysis 2024; 57:918-928. [PMID: 38762710 DOI: 10.1007/s11239-024-02998-9] [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] [Accepted: 04/30/2024] [Indexed: 05/20/2024]
Abstract
Hemodynamic assessment of patients with pulmonary embolism (PE) remains a fundamental component of early risk stratification that in turn, influences subsequent monitoring and therapeutic strategies. The current body of literature and international evidence-based clinical practice guidelines focus mainly on the use of systolic blood pressure (SBP). The accuracy of this single hemodynamic parameter, however, and its optimal values for the identification of hemodynamic instability have been recently questioned by clinicians. For example, abnormal SBP or shock index may be a late indicator of adverse outcomes, signaling a patient in whom the cascade of hemodynamic compromise is already well underway. The aim of the present article is to review the current evidence supporting the use of SBP and analyze the potential integration of other parameters to assess the hemodynamic stability, impending clinical deterioration, and guide the reperfusion treatment in patients with PE, as well as to suggest potential strategies to further investigate this issue.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Via Aldo Moro 8, Ferrara, 44124, Italy.
| | | | - Eileen M Harder
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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3
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Slessarev M, Bain KL, Basmaji J, Blydt-Hansen TD, Cooper J, D'Aragon F, Del Sorbo L, Evans A, Gordon AC, Klein G, Meade MO, Murphy N, Thomas HL, Weiss MJ, Weijer C, Harvey D. Developing Guidance for Donor Intervention Randomized Controlled Trials: Initial Discussions From the Canada-United Kingdom 2022 Workshop. Transplantation 2024; 108:1776-1781. [PMID: 38499505 DOI: 10.1097/tp.0000000000004983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Donor interventions, including medications, protocols, and medical devices administered to donors, can enhance transplantable organ quality and quantity and maximize transplantation success. However, there is paucity of high-quality evidence about their effectiveness, in part because of ethical, practical, and regulatory challenges, and lack of guidance about conduct of donor intervention randomized controlled trials (RCTs). METHODS With the vision to develop authoritative guidance for conduct of donor intervention RCTs, we convened a workshop of Canadian-United Kingdom experts in organ donation and transplantation ethics, research, and policy to identify stakeholders, explore unique challenges, and develop research agenda to inform future work in this promising field. RESULTS Donor intervention trials should consider perspectives of broad group of stakeholders including donors, transplant recipients, and their families; researchers in donation and transplantation; research ethics boards; and healthcare providers and administrators involved in donation and transplantation. Unique challenges include (1) research ethics (living versus deceased status of the donor at the time of intervention, intervention versus outcomes assessment in different individuals, harm-benefit analysis in donors versus recipients, consent, and impact on research bystanders); (2) outcome data standardization and linkage; and (3) regulatory and governance considerations. CONCLUSIONS Donor intervention RCTs hold potential to benefit organ transplantation outcomes but face unique research ethics, outcome data, and regulatory challenges. By developing research agenda to address these challenges, our workshop was an important first step toward developing Canada-United Kingdom guidance for donor intervention RCTs that are poised to improve the quality and availability of transplantable organs.
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Affiliation(s)
- Marat Slessarev
- Department of Medicine, Western University, London, ON, Canada
- The Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
| | - Katie L Bain
- The Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - John Basmaji
- Department of Medicine, Western University, London, ON, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics (Nephrology), University of British Columbia, Vancouver, BC, Canada
| | - Jessie Cooper
- Department of Health Services Research and Management, School of Health & Psychological Sciences, City, University of London, London, United Kingdom
| | - Frédérick D'Aragon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du CHU de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie-Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Amy Evans
- NHS Blood and Transplant, Clinical Trials Unit, Bristol, United Kingdom
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London United Kingdom
| | - Gail Klein
- Centre for Clinical Trial Support, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Maureen O Meade
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Nicholas Murphy
- Department of Medicine, Western University, London, ON, Canada
- The Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Philosophy, Western University, London, ON, Canada
| | - Helen L Thomas
- NHS Blood and Transplant, Clinical Trials Unit, Bristol, United Kingdom
| | - Matthew J Weiss
- The Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Transplant Québec, Montréal, QC, Canada
- Division of Critical Care, Department of Pediatrics, Centre Mère-Enfant Soleil du CHU de Québec, Québec, QC, Canada
| | - Charles Weijer
- Department of Medicine, Western University, London, ON, Canada
- Department of Philosophy, Western University, London, ON, Canada
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Dan Harvey
- NHS Blood and Transplant, University of Nottingham, Nottingham, United Kingdom
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Prentice HA, Harris JE, Sucher K, Fasig BH, Navarro RA, Okike KM, Maletis GB, Guppy KH, Chang RW, Kelly MP, Hinman AD, Paxton EW. Improvements in Quality, Safety and Costs Associated with Use of Implant Registries Within a Health System. Jt Comm J Qual Patient Saf 2024; 50:404-415. [PMID: 38368191 DOI: 10.1016/j.jcjq.2024.01.011] [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: 08/04/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Clinical quality registries (CQRs) are intended to enhance quality, safety, and cost reduction using real-world data for a self-improving health system. Starting in 2001, Kaiser Permanente established several medical device CQRs as a quality improvement initiative. This report examines the contributions of these CQRs on improvement in health outcomes, changes in clinical practice, and cost-effectiveness over the past 20 years. METHODS Eight implant registries were instituted with standardized collection from the electronic health record and other institutional data sources of patient characteristics, medical comorbidities, implant attributes, procedure details, surgical techniques, and outcomes (including complications, revisions, reoperations, hospital readmissions, and other utilization measures). A rigorous quality control system is in place to improve and maintain the quality of data. Data from the Implant Registries form the basis for multiple quality improvement and patient safety initiatives to minimize variation in care, promote clinical best practices, facilitate recalls, perform benchmarking, identify patients at risk, and construct reports about individual surgeons. RESULTS Following the inception of the Implant Registries, there was an observed (1) reduction in opioid utilization following orthopedic procedures, (2) reduction in use of bone morphogenic protein during lumbar fusion allowing for cost savings, (3) reduction in allograft for anterior cruciate ligament reconstruction and subsequent decrease in organizationwide revision rates, (4) cost savings through expansion of same-day discharge programs for joint arthroplasty, (5) increase in the use of cement fixation in the hemiarthroplasty treatment of hip fracture, and (6) organizationwide discontinuation of an endograft device associated with a higher risk for adverse outcomes following endovascular aortic aneurysm repair. CONCLUSION The use of Implant Registries within our health system, along with clinical leadership and organizational commitment to a learning health system, was associated with improved quality and safety outcomes and reduced costs. The exact mechanisms by which such registries affect health outcomes and costs require further study.
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Sun F, Bedenkov A, Liu BC, Yang J, Xu JF, Ji L, Zhou M, Zhang S, Li X, Song Y, Chen P, Moreno C. Maximizing the Value of Real-World Data and Real-World Evidence to Accelerate Healthcare Transformation in China: Summary of External Advisory Committee Meetings. Pharmaceut Med 2024; 38:157-166. [PMID: 38573457 PMCID: PMC11101539 DOI: 10.1007/s40290-024-00520-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2024] [Indexed: 04/05/2024]
Abstract
Use of real-world data (RWD) is gaining wide attention. To bridge the gap between diverse healthcare stakeholders and to leverage the impact of Chinese real-world evidence (RWE) globally, a multi-stakeholder External Advisory Committee (EAC) and EAC meetings were initiated, aiming to elucidate the current and evolving RWD landscape in China, articulate the values of RWE in ensuring Chinese patients' equitable access to affordable medicines and solutions, and identify strategic opportunities and partnerships for expansion of RWE generation in China. Chinese and international experts who are clinicians and academic researchers were selected as EAC members based on their professional background and familiarity with RWD/RWE. Three EAC meetings were held quarterly in 2023. Various topics were presented and discussed for insights and suggestions. Nine experts from China, one from South Korea, and two from Europe were selected as EAC members and attended these meetings. Experts' presentations were summarized by theme, including the RWD landscape and RWE enablement in China, as well as global development of a patient-centric ecosystem. Experts' insights and suggestions on maximizing the RWD/RWE value to accelerate healthcare transformation in China were collected. We concluded that though data access, sharing, and quality are still challenging, RWD is developing to support evidence generation in the medicinal product lifecycle, inform clinical practice, and empower patient management in China. RWD/RWE creates value, accelerates healthcare transformation, and improves patient outcomes. Fostering a patient-centric ecosystem across healthcare stakeholders and maintaining global partnerships and collaboration are essential for unlocking the power of RWD/RWE.
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Affiliation(s)
- Feng Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Peking University, Beijing, China
| | | | - Bi-Cheng Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Jiefu Yang
- Department of Cardiology, Beijing Hospital, Beijing, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Peking University Diabetes Center, Beijing, China
| | - Min Zhou
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shaosen Zhang
- Global Evidence Powerhub China, AstraZeneca, Shanghai, China
| | - Xinli Li
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuanlin Song
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pingyan Chen
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China.
- Hainan Institute of Real-World Data, Qionghai, China.
| | - Carmen Moreno
- Global Evidence Powerhub China, AstraZeneca, Shanghai, China.
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Van Spall HGC, Bastien A, Gersh B, Greenberg B, Mohebi R, Min J, Strauss K, Thirstrup S, Zannad F. The role of early-phase trials and real-world evidence in drug development. NATURE CARDIOVASCULAR RESEARCH 2024; 3:110-117. [PMID: 39196202 DOI: 10.1038/s44161-024-00420-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/22/2023] [Indexed: 08/29/2024]
Abstract
Phase 3 randomized controlled trials (RCTs), while the gold standard for treatment efficacy and safety, are not always feasible, are expensive, can be prolonged and can be limited in generalizability. Other under-recognized sources of evidence can also help advance drug development. Basic science, proof-of-concept studies and early-phase RCTs can provide evidence regarding the potential for clinical benefit. Real-world evidence generated from registries or observational datasets can provide insights into the treatment of rare diseases that often pose a challenge for trial recruitment. Pragmatic trials embedded in healthcare systems can assess the treatment effects in clinical settings among patient populations sometimes excluded from trials. This Perspective discusses potential sources of evidence that may be used to complement explanatory phase 3 RCTs and to speed the development of new cardiovascular medications. Content is derived from the 19th Global Cardiovascular Clinical Trialists meeting (December 2022), involving clinical trialists, patients, clinicians, regulators, funders and industry representatives.
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Affiliation(s)
- Harriette G C Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact; Research Institute of St. Joseph's, McMaster University, Hamilton, Ontario, Canada
- Baim Institute for Clinical Research, Boston, MA, USA
| | | | - Bernard Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Barry Greenberg
- Division of Cardiology, UC San Diego Health, San Diego, CA, USA
| | - Reza Mohebi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Faiez Zannad
- Université de Lorraine, Inserm Clinical Investigation Center at Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy, Nancy, France.
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Matsumoto H, Ogura H, Oda J. Analysis of comprehensive biomolecules in critically ill patients via bioinformatics technologies. Acute Med Surg 2024; 11:e944. [PMID: 38596160 PMCID: PMC11002317 DOI: 10.1002/ams2.944] [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: 10/11/2023] [Revised: 02/23/2024] [Accepted: 03/10/2024] [Indexed: 04/11/2024] Open
Abstract
Each patient with a critical illness such as sepsis and severe trauma has a different genetic background, comorbidities, age, and sex. Moreover, pathophysiology changes dynamically over time even in the same patient. Therefore, individualized treatment is necessary to account for heterogeneity in patient backgrounds. Recently, the analysis of comprehensive biomolecular information using clinical specimens has revealed novel molecular pathological classifications called subtypes. In addition, comprehensive biomolecular information using clinical specimens has enabled reverse translational research, which is a data-driven approach to the identification of drug target molecules. The development of these methods is expected to visualize the heterogeneity of patient backgrounds and lead to personalized therapy.
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Affiliation(s)
- Hisatake Matsumoto
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineSuitaOsakaJapan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineSuitaOsakaJapan
| | - Jun Oda
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineSuitaOsakaJapan
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Semple RK, Patel KA, Auh S, Brown RJ. Genotype-stratified treatment for monogenic insulin resistance: a systematic review. COMMUNICATIONS MEDICINE 2023; 3:134. [PMID: 37794082 PMCID: PMC10550936 DOI: 10.1038/s43856-023-00368-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 09/20/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Monogenic insulin resistance (IR) includes lipodystrophy and disorders of insulin signalling. We sought to assess the effects of interventions in monogenic IR, stratified by genetic aetiology. METHODS Systematic review using PubMed, MEDLINE and Embase (1 January 1987 to 23 June 2021). Studies reporting individual-level effects of pharmacologic and/or surgical interventions in monogenic IR were eligible. Individual data were extracted and duplicates were removed. Outcomes were analysed for each gene and intervention, and in aggregate for partial, generalised and all lipodystrophy. RESULTS 10 non-randomised experimental studies, 8 case series, and 23 case reports meet inclusion criteria, all rated as having moderate or serious risk of bias. Metreleptin use is associated with the lowering of triglycerides and haemoglobin A1c (HbA1c) in all lipodystrophy (n = 111), partial (n = 71) and generalised lipodystrophy (n = 41), and in LMNA, PPARG, AGPAT2 or BSCL2 subgroups (n = 72,13,21 and 21 respectively). Body Mass Index (BMI) is lowered in partial and generalised lipodystrophy, and in LMNA or BSCL2, but not PPARG or AGPAT2 subgroups. Thiazolidinediones are associated with improved HbA1c and triglycerides in all lipodystrophy (n = 13), improved HbA1c in PPARG (n = 5), and improved triglycerides in LMNA (n = 7). In INSR-related IR, rhIGF-1, alone or with IGFBP3, is associated with improved HbA1c (n = 17). The small size or absence of other genotype-treatment combinations preclude firm conclusions. CONCLUSIONS The evidence guiding genotype-specific treatment of monogenic IR is of low to very low quality. Metreleptin and Thiazolidinediones appear to improve metabolic markers in lipodystrophy, and rhIGF-1 appears to lower HbA1c in INSR-related IR. For other interventions, there is insufficient evidence to assess efficacy and risks in aggregated lipodystrophy or genetic subgroups.
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Affiliation(s)
- Robert K Semple
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Kashyap A Patel
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Sungyoung Auh
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca J Brown
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
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Bacchi S, Kovoor J, Gupta A, Chan W. Registries required: A coordinated approach facilitates novel insights. Clin Exp Ophthalmol 2023; 51:650-651. [PMID: 37254624 DOI: 10.1111/ceo.14263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/10/2023] [Accepted: 04/14/2023] [Indexed: 06/01/2023]
Affiliation(s)
- Stephen Bacchi
- Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua Kovoor
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Aashray Gupta
- University of Adelaide, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - WengOnn Chan
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Semple RK, Patel KA, Auh S, Brown RJ. Systematic review of genotype-stratified treatment for monogenic insulin resistance. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.17.23288671. [PMID: 37205502 PMCID: PMC10187355 DOI: 10.1101/2023.04.17.23288671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Objective To assess the effects of pharmacologic and/or surgical interventions in monogenic insulin resistance (IR), stratified by genetic aetiology. Design Systematic review. Data sources PubMed, MEDLINE and Embase, from 1 January 1987 to 23 June 2021. Review methods Studies reporting individual-level effects of pharmacologic and/or surgical interventions in monogenic IR were eligible. Individual subject data were extracted and duplicate data removed. Outcomes were analyzed for each affected gene and intervention, and in aggregate for partial, generalised and all lipodystrophy. Results 10 non-randomised experimental studies, 8 case series, and 21 single case reports met inclusion criteria, all rated as having moderate or serious risk of bias. Metreleptin was associated with lower triglycerides and hemoglobin A1c in aggregated lipodystrophy (n=111), in partial lipodystrophy (n=71) and generalised lipodystrophy (n=41)), and in LMNA , PPARG , AGPAT2 or BSCL2 subgroups (n=72,13,21 and 21 respectively). Body Mass Index (BMI) was lower after treatment in partial and generalised lipodystrophy overall, and in LMNA or BSCL2 , but not PPARG or AGPAT2 subgroups. Thiazolidinedione use was associated with improved hemoglobin A1c and triglycerides in aggregated lipodystrophy (n=13), improved hemoglobin A1c only in the PPARG subgroup (n=5), and improved triglycerides only in the LMNA subgroup (n=7). In INSR -related IR, use of rhIGF-1, alone or with IGFBP3, was associated with improved hemoglobin A1c (n=15). The small size or absence of all other genotype-treatment combinations precluded firm conclusions. Conclusions The evidence guiding genotype-specific treatment of monogenic IR is of low to very low quality. Metreleptin and Thiazolidinediones appear to have beneficial metabolic effects in lipodystrophy, and rhIGF-1 appears to lower hemoglobin A1c in INSR-related IR. For other interventions there is insufficient evidence to assess efficacy and risks either in aggregated lipodystrophy or in genetic subgroups. There is a pressing need to improve the evidence base for management of monogenic IR.
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Affiliation(s)
- Robert K. Semple
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Kashyap A. Patel
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Sungyoung Auh
- Office of the Clinical Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - ADA/EASD PMDI
- American Diabetes Association/European Association for the Study of Diabetes Precision Medicine in Diabetes Initiative
| | - Rebecca J. Brown
- National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health. Bethesda, MD, USA
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