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Tay J, Robinson C, Blazeby J, Loke Y, Lowery A, Alkhaffaf B, Kirkham JJ. Inclusion of harm outcomes in core outcome sets requires careful consideration. J Clin Epidemiol 2024; 174:111474. [PMID: 39038744 DOI: 10.1016/j.jclinepi.2024.111474] [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: 03/21/2024] [Revised: 05/13/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024]
Abstract
OBJECTIVES The objective of this study was to determine the proportion of all published core outcome set (COS) studies that include an adverse event or harm outcome, to determine the proportion of individual vs pooled harms, and to investigate characteristics that influence their inclusion. METHODS We examined the extent to which a sample of 100 published COS studies (from January 2021 to January 2023) include both pooled and individual harms in the final COS. One investigator extracted the information from the COS studies, which was cross-checked against previous COS investigational research, and where possible verified with COS authors or a pharmacologist. Using Qualtrics™, we conducted a personalized online survey of developers of the 100 COS to ask them about the importance, their experiences, and methodological approaches for dealing with harms within their COS development studies. RESULTS One hundred COS were identified from 91 separate COS studies, the majority of which considered most of the minimum standards for development. Two-thirds (65%) of the COS included at least 1 harm outcome. In total, 1104 core outcomes were identified across the 100 COS, of which 184 (17%) were harm outcomes (154 individual vs 56 pooled). Individual harms were more likely to be included in a final COS if they were developed for single treatment interventions (50%) compared to those being developed for multitreatment modalities (39%). Some COS developers adopted outcome frameworks as part of their COS development process to facilitate the inclusion of harm outcomes in their final COS. A third (33%) of respondents felt that harm outcomes should be included in all COS but over half (56%) thought this would be dependent on some aspect of the scope of the COS and improved methodology and awareness of how to deal with harm outcomes in the COS development process. CONCLUSION Harm outcomes are already included in many COS either as individual or pooled harms. It is evident that there are some challenges with regards to both the methodology and necessity to include harms within a COS (pooled or individual. COS developers should carefully consider the need to include important harms outcomes in relation to the scope of the COS that they are developing.
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Affiliation(s)
- Joel Tay
- Centre for Biostatistics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| | - Catherine Robinson
- Social Care and Society, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Jane Blazeby
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Aoife Lowery
- Discipline of Surgery, University of Galway, Galway, Ireland
| | - Bilal Alkhaffaf
- Department of Oesophago-Gastric and Bariatric Surgery, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jamie J Kirkham
- Centre for Biostatistics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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2
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Lyu T, Bornkamp B, Mueller-Velten G, Schmidli H. Bayesian inference for a principal stratum estimand on recurrent events truncated by death. Biometrics 2023; 79:3792-3802. [PMID: 36647690 DOI: 10.1111/biom.13831] [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: 01/12/2022] [Accepted: 01/05/2023] [Indexed: 01/18/2023]
Abstract
Recurrent events are often important endpoints in randomized clinical trials. For example, the number of recurrent disease-related hospitalizations may be considered as a clinically meaningful endpoint in cardiovascular studies. In some settings, the recurrent event process may be terminated by an event such as death, which makes it more challenging to define and estimate a causal treatment effect on recurrent event endpoints. In this paper, we focus on the principal stratum estimand, where the treatment effect of interest on recurrent events is defined among subjects who would be alive regardless of the assigned treatment. For the estimation of the principal stratum effect in randomized clinical trials, we propose a Bayesian approach based on a joint model of the recurrent event and death processes with a frailty term accounting for within-subject correlation. We also present Bayesian posterior predictive check procedures for assessing the model fit. The proposed approaches are demonstrated in the randomized Phase III chronic heart failure trial PARAGON-HF (NCT01920711).
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Affiliation(s)
- Tianmeng Lyu
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
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3
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Junqueira DR, Zorzela L, Golder S, Loke Y, Gagnier JJ, Julious SA, Li T, Mayo-Wilson E, Pham B, Phillips R, Santaguida P, Scherer RW, Gøtzsche PC, Moher D, Ioannidis JPA, Vohra S. CONSORT Harms 2022 statement, explanation, and elaboration: updated guideline for the reporting of harms in randomized trials. J Clin Epidemiol 2023; 158:149-165. [PMID: 37100738 DOI: 10.1016/j.jclinepi.2023.04.005] [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] [Accepted: 03/21/2023] [Indexed: 04/28/2023]
Abstract
Randomized controlled trials remain the reference standard for healthcare research on effects of interventions, and the need to report both benefits and harms is essential. The Consolidated Standards of Reporting Trials (the main CONSORT) statement includes one item on reporting harms (i.e., all important harms or unintended effects in each group). In 2004, the CONSORT group developed the CONSORT Harms extension; however, it has not been consistently applied and needs to be updated. Here, we describe CONSORT Harms 2022, which replaces the CONSORT Harms 2004 checklist, and shows how CONSORT Harms 2022 items could be incorporated into the main CONSORT checklist. Thirteen items from the main CONSORT were modified to improve harms reporting. Three new items were added. In this article, we describe CONSORT Harms 2022 and how it was integrated into the main CONSORT checklist and elaborate on each item relevant to complete reporting of harms in randomized controlled trials. Until future work from the CONSORT group produces an updated checklist, authors, journal reviewers, and editors of randomized controlled trials should use the integrated checklist presented in this paper.
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Affiliation(s)
- Daniela R Junqueira
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Liliane Zorzela
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Susan Golder
- Department of Health Sciences, University of York, York, UK
| | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Joel J Gagnier
- Department of Epidemiology and Biostatistics, Department of Surgery, Western University, London, Ontario, Canada
| | - Steven A Julious
- Design, Trials and Statistics, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Tianjing Li
- Department of Ophthalmology, School of Medicine, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Evan Mayo-Wilson
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Ba Pham
- Knowledge Translation Programme, Unity Health Toronto, Toronto, Ontario, Canada
| | - Rachel Phillips
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Pasqualina Santaguida
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | | | | | - David Moher
- Centre for Journalology, Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - John P A Ioannidis
- Departments of Medicine, of Epidemiology and Population Health, of Biomedical Data Science, and of Statistics, Stanford University, Stanford, CA, USA
| | - Sunita Vohra
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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4
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Junqueira DR, Zorzela L, Golder S, Loke Y, Gagnier JJ, Julious SA, Li T, Mayo-Wilson E, Pham B, Phillips R, Santaguida P, Scherer RW, Gøtzsche PC, Moher D, Ioannidis JPA, Vohra S. CONSORT Harms 2022 statement, explanation, and elaboration: updated guideline for the reporting of harms in randomised trials. BMJ 2023; 381:e073725. [PMID: 37094878 DOI: 10.1136/bmj-2022-073725] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Affiliation(s)
- Daniela R Junqueira
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Liliane Zorzela
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Susan Golder
- Department of Health Sciences, University of York, York, UK
| | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Joel J Gagnier
- Department of Epidemiology and Biostatistics, Department of Surgery, Western University, London, ON, Canada
| | - Steven A Julious
- Design, Trials and Statistics, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Tianjing Li
- Department of Ophthalmology, School of Medicine, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Evan Mayo-Wilson
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Ba Pham
- Knowledge Translation Programme, Unity Health Toronto, Toronto, ON, Canada
| | - Rachel Phillips
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Pasqualina Santaguida
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | | | | | - David Moher
- Centre for Journalology, Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - John P A Ioannidis
- Departments of Medicine, of Epidemiology and Population Health, of Biomedical Data Science, and of Statistics, Stanford University, Stanford, CA, USA
| | - Sunita Vohra
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Ponjoan A, Jacques-Aviñó C, Medina-Perucha L, Romero V, Martí-Lluch R, Alves-Cabratosa L, Ramos R, Berenguera A, Garcia-Gil MDM. Axes of social inequities in COVID-19 clinical trials: A systematic review. Front Public Health 2023; 11:1069357. [PMID: 36891333 PMCID: PMC9987589 DOI: 10.3389/fpubh.2023.1069357] [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: 10/13/2022] [Accepted: 01/16/2023] [Indexed: 02/16/2023] Open
Abstract
Objective The representativeness of participants is crucial to ensure external validity of clinical trials. We focused on the randomized clinical trials which assessed COVID-19 vaccines to assess the reporting of age, sex, gender identity, race, ethnicity, obesity, sexual orientation, and socioeconomic status in the results (description of the participants' characteristics, loss of follow-up, stratification of efficacy and safety results). Methods We searched the following databases for randomized clinical trials published before 1st February 2022: PubMed, Scopus, Web of Science, and Excerpta Medica. We included peer-reviewed articles written in English or Spanish. Four researchers used the Rayyan platform to filter citations, first reading the title and abstract, and then accessing the full text. Articles were excluded if both reviewers agreed, or if a third reviewer decided to discard them. Results Sixty three articles were included, which assessed 20 different vaccines, mainly in phase 2 or 3. When describing the participants' characteristics, all the studies reported sex or gender, 73.0% race, ethnicity, 68.9% age groups, and 22.2% obesity. Only one article described the age of participants lost to follow-up. Efficacy results were stratified by age in 61.9%, sex or gender in 26.9%, race and/or, ethnicity in 9.5%, and obesity in 4.8% of the articles. Safety results were stratified by age in 41.0%, and by sex or gender in 7.9% of the analysis. Reporting of gender identity, sexual orientation or socioeconomic status of participants was rare. Parity was reached in 49.2% of the studies, and sex-specific outcomes were mentioned in 22.9% of the analysis, most of the latter were related to females' health. Conclusions Axes of social inequity other than age and sex were hardly reported in randomized clinical trials that assessed COVID-19 vaccines. This undermines their representativeness and external validity and sustains health inequities.
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Affiliation(s)
- Anna Ponjoan
- Grup en Salut Vascular de Girona (ISV-Girona), Institut Universitari d'Investigació en Atenció Primària (IDIAPJGol), Girona, Spain.,Institut d'Investigació Biomèdica de Girona Dr. Josep Trueta (IDIBGI), Girona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Constanza Jacques-Aviñó
- Universitat Autònoma de Barcelona, Bellaterra, Spain.,Institut Universitari d'Investigació en Atenció Primària (IDIAPJGol), Barcelona, Spain
| | - Laura Medina-Perucha
- Universitat Autònoma de Barcelona, Bellaterra, Spain.,Institut Universitari d'Investigació en Atenció Primària (IDIAPJGol), Barcelona, Spain
| | - Victor Romero
- Servicio Canario de la Salud, Santa Cruz de Tenerife, Spain
| | - Ruth Martí-Lluch
- Grup en Salut Vascular de Girona (ISV-Girona), Institut Universitari d'Investigació en Atenció Primària (IDIAPJGol), Girona, Spain.,Institut d'Investigació Biomèdica de Girona Dr. Josep Trueta (IDIBGI), Girona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Lia Alves-Cabratosa
- Grup en Salut Vascular de Girona (ISV-Girona), Institut Universitari d'Investigació en Atenció Primària (IDIAPJGol), Girona, Spain
| | - Rafel Ramos
- Grup en Salut Vascular de Girona (ISV-Girona), Institut Universitari d'Investigació en Atenció Primària (IDIAPJGol), Girona, Spain.,Department of Medical Sciences, School of Medicine, Universitat de Girona, Girona, Spain
| | - Anna Berenguera
- Institut Universitari d'Investigació en Atenció Primària (IDIAPJGol), Barcelona, Spain.,Department of Nursing, Universitat de Girona, Girona, Spain
| | - María Del Mar Garcia-Gil
- Grup en Salut Vascular de Girona (ISV-Girona), Institut Universitari d'Investigació en Atenció Primària (IDIAPJGol), Girona, Spain
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6
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Hodkinson A, Tsimpida D, Kontopantelis E, Rutter MK, Mamas MA, Panagioti M. Comparative effectiveness of statins on non-high density lipoprotein cholesterol in people with diabetes and at risk of cardiovascular disease: systematic review and network meta-analysis. BMJ 2022; 376:e067731. [PMID: 35331984 PMCID: PMC8943592 DOI: 10.1136/bmj-2021-067731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the efficacy of different statin treatments by intensity on levels of non-high density lipoprotein cholesterol (non-HDL-C) for the prevention of cardiovascular disease in people with diabetes. DESIGN Systematic review and network meta-analysis. DATA SOURCES Medline, Cochrane Central Register of Controlled Trials, and Embase from inception to 1 December 2021. REVIEW METHODS Randomised controlled trials comparing different types and intensities of statins, including placebo, in adults with type 1 or type 2 diabetes mellitus were included. The primary outcome was changes in levels of non-HDL-C, calculated from measures of total cholesterol and HDL-C. Secondary outcomes were changes in levels of low density lipoprotein cholesterol (LDL-C) and total cholesterol, three point major cardiovascular events (non-fatal stroke, non-fatal myocardial infarction, and death related to cardiovascular disease), and discontinuations because of adverse events. A bayesian network meta-analysis of statin intensity (low, moderate, or high) with random effects evaluated the treatment effect on non-HDL-C by mean differences and 95% credible intervals. Subgroup analysis of patients at greater risk of major cardiovascular events was compared with patients at low or moderate risk. The confidence in network meta-analysis (CINeMA) framework was applied to determine the certainty of evidence. RESULTS In 42 randomised controlled trials involving 20 193 adults, 11 698 were included in the meta-analysis. Compared with placebo, the greatest reductions in levels of non-HDL-C were seen with rosuvastatin at high (-2.31 mmol/L, 95% credible interval -3.39 to -1.21) and moderate (-2.27, -3.00 to -1.49) intensities, and simvastatin (-2.26, -2.99 to -1.51) and atorvastatin (-2.20, -2.69 to -1.70) at high intensity. Atorvastatin and simvastatin at any intensity and pravastatin at low intensity were also effective in reducing levels of non-HDL-C. In 4670 patients at greater risk of a major cardiovascular events, atorvastatin at high intensity showed the largest reduction in levels of non-HDL-C (-1.98, -4.16 to 0.26, surface under the cumulative ranking curve 64%). Simvastatin (-1.93, -2.63 to -1.21) and rosuvastatin (-1.76, -2.37 to -1.15) at high intensity were the most effective treatment options for reducing LDL-C. Significant reductions in non-fatal myocardial infarction were found for atorvastatin at moderate intensity compared with placebo (relative risk=0.57, confidence interval 0.43 to 0.76, n=4 studies). No significant differences were found for discontinuations, non-fatal stroke, and cardiovascular deaths. CONCLUSIONS This network meta-analysis indicated that rosuvastatin, at moderate and high intensity doses, and simvastatin and atorvastatin, at high intensity doses, were most effective at moderately reducing levels of non-HDL-C in patients with diabetes. Given the potential improvement in accuracy in predicting cardiovascular disease when reduction in levels of non-HDL-C is used as the primary target, these findings provide guidance on which statin types and intensities are most effective by reducing non-HDL-C in patients with diabetes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021258819.
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Affiliation(s)
- Alexander Hodkinson
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Dialechti Tsimpida
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Institute for Health Policy and Organisation, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Division of Medical Education, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Institute for Health Policy and Organisation, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Division of Informatics, Imaging, and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Martin K Rutter
- Division of Diabetes, Endocrinology, and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Diabetes, Endocrinology, and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mamas A Mamas
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Maria Panagioti
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
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Mueller‐Leisse J, Brunn J, Zormpas C, Hohmann S, Hillmann HAK, Eiringhaus J, Bauersachs J, Veltmann C, Duncker D. Extended follow-up after wearable cardioverter-defibrillator period: the PROLONG-II study. ESC Heart Fail 2021; 8:5142-5148. [PMID: 34480414 PMCID: PMC8712878 DOI: 10.1002/ehf2.13586] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/29/2021] [Accepted: 08/19/2021] [Indexed: 11/05/2022] Open
Abstract
AIM The wearable cardioverter-defibrillator (WCD) is used for temporary protection from sudden cardiac death (SCD) in patients with newly diagnosed heart failure with reduced ejection fraction before considering an implantable cardioverter-defibrillator (ICD). However, the prognostic significance of the WCD remains controversial due to conflicting evidence. The aim of the present study was to evaluate prognosis of patients receiving life-saving WCD shocks. METHODS AND RESULTS All patients receiving a WCD at Hannover Medical School for heart failure with reduced ejection fraction between 2012 and 2017 were included. Data were acquired at baseline, at 3 months and at last available follow-up (FU). Three hundred and fifty-three patients were included (69% male; age 56 ± 15 years; left ventricular ejection fraction 25 ± 8%). FU after the WCD was 2.8 ± 1.5 years with a maximum of 6.8 years. Daily WCD wear time was 22 ± 4 h. Fourteen patients (4%) received appropriate WCD shocks. Two patients (0.6%) died during the WCD period. Thirty patients (9%) died during extended FU. Mean estimated survival after the WCD was similar between patients with and without WCD shocks. Patients without an ICD recommendation after WCD prescription did not experience SCD during FU. CONCLUSIONS Patients with WCD shocks showed a favourable survival. Patients without an ICD recommendation after WCD prescription had no SCD during FU. These findings support the practice of careful risk stratification before considering an ICD and the use of the WCD for temporary protection from SCD.
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Affiliation(s)
- Johanna Mueller‐Leisse
- Hannover Heart Rhythm Center, Department of Cardiology and AngiologyHannover Medical SchoolCarl‐Neuberg‐Str. 1Hannover30625Germany
| | - Johanna Brunn
- Hannover Heart Rhythm Center, Department of Cardiology and AngiologyHannover Medical SchoolCarl‐Neuberg‐Str. 1Hannover30625Germany
| | - Christos Zormpas
- Hannover Heart Rhythm Center, Department of Cardiology and AngiologyHannover Medical SchoolCarl‐Neuberg‐Str. 1Hannover30625Germany
| | - Stephan Hohmann
- Hannover Heart Rhythm Center, Department of Cardiology and AngiologyHannover Medical SchoolCarl‐Neuberg‐Str. 1Hannover30625Germany
| | - Henrike Aenne Katrin Hillmann
- Hannover Heart Rhythm Center, Department of Cardiology and AngiologyHannover Medical SchoolCarl‐Neuberg‐Str. 1Hannover30625Germany
| | - Jörg Eiringhaus
- Hannover Heart Rhythm Center, Department of Cardiology and AngiologyHannover Medical SchoolCarl‐Neuberg‐Str. 1Hannover30625Germany
| | - Johann Bauersachs
- Hannover Heart Rhythm Center, Department of Cardiology and AngiologyHannover Medical SchoolCarl‐Neuberg‐Str. 1Hannover30625Germany
| | - Christian Veltmann
- Hannover Heart Rhythm Center, Department of Cardiology and AngiologyHannover Medical SchoolCarl‐Neuberg‐Str. 1Hannover30625Germany
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and AngiologyHannover Medical SchoolCarl‐Neuberg‐Str. 1Hannover30625Germany
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8
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Baer BR, Fremes SE, Gaudino M, Charlson M, Wells MT. On clinical trial fragility due to patients lost to follow up. BMC Med Res Methodol 2021; 21:254. [PMID: 34800976 PMCID: PMC8606097 DOI: 10.1186/s12874-021-01446-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/19/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Clinical trials routinely have patients lost to follow up. We propose a methodology to understand their possible effect on the results of statistical tests by altering the concept of the fragility index to treat the outcomes of observed patients as fixed but incorporate the potential outcomes of patients lost to follow up as random and subject to modification. METHODS We reanalyse the statistical results of three clinical trials on coronary artery bypass grafting (CABG) to study the possible effect of patients lost to follow up on the treatment effect statistical significance. To do so, we introduce the LTFU-aware fragility indices as a measure of the robustness of a clinical trial's statistical results with respect to patients lost to follow up. RESULTS The analyses illustrate that clinical trials can either be completely robust to the outcomes of patients lost to follow up, extremely sensitive to the outcomes of patients lost to follow up, or in an intermediate state. When a clinical trial is in an intermediate state, the LTFU-aware fragility indices provide an interpretable measure to quantify the degree of fragility or robustness. CONCLUSIONS The LTFU-aware fragility indices allow researchers to rigorously explore the outcomes of patients who are lost to follow up, when their data is the appropriate kind. The LTFU-aware fragility indices are sensitivity measures in a way that the original fragility index is not.
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Affiliation(s)
- Benjamin R. Baer
- Department of Statistics and Data Science, Cornell University, Ithaca, NY US
| | - Stephen E. Fremes
- Schulich Heart Centre, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON Canada
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY US
| | - Mary Charlson
- Department of Medicine, Weill Cornell Medicine, Weill Cornell Medicine, New York, NY US
| | - Martin T. Wells
- Department of Statistics and Data Science, Cornell University, Ithaca, NY US
- Department of Medicine, Weill Cornell Medicine, Weill Cornell Medicine, New York, NY US
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9
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Cabrita BMO, Galego MA, Fernandes AL, Dias S, Correia S, Simão P, Ferreira J, Amado J. Follow-up loss in smoking cessation consultation: can we predict and prevent it? J Thorac Dis 2021; 13:2331-2338. [PMID: 34012582 PMCID: PMC8107513 DOI: 10.21037/jtd-20-1832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Cigarette smoking has a considerable health and economic burden in modern society, with increased risk of morbidity and mortality. Therefore, smoking cessation policies and medical treatments are essential. However, cessation rates are low and the abandonment of the consultation is common. The identification of characteristics that may predict adherence will help defining the best treatment strategy. This study aimed to identify predictors of follow-up loss in smoking cessation consultation. Methods We made a retrospective observational study, including a cohort of patients who started smoking cessation consultation (April-December 2018). Clinical data from consultations was collected and analyzed with IBM SPSS Statistics (SPSS, RRID:SCR_002865). Results A total of 175 patients was selected (41.1% female), with a mean age of 53±12 years. Eighty-five patients (48.6%) were discharged for abandonment. They had a median pack-year unit 38±36 (P=0.011), Fagerström and Richmond scores of 5±2 and 7±2, respectively. There was an association between women (P<0.001), younger age (P<0.001), depression/anxiety (P=0.023), lower smoking load (P=0.019), starting the treatment in the first appointment (P=0.004) and the abandonment of the consultation. In binary logistic regression, younger age (less than 50 years) (OR =4.39; 95% CI: 1.99-9.70), starting the treatment in the first appointment (OR =3.04; 95% CI: 1.44-6.42) and depression/anxiety (OR =2.30; 95% CI: 1.08-4.88) remained independent predictors of loss in follow-up. Conclusions Women, younger age, depression/anxiety, lower smoking load and starting treatment in the first appointment are predictors of follow-up loss, so, these patients may benefit from more frequent evaluations and intensive cognitive approach. This study also raises awareness about the adequate timing to start pharmacological support for smoking cessation.
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Affiliation(s)
| | | | | | - Sara Dias
- Pulmonology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Sílvia Correia
- Pulmonology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Paula Simão
- Pulmonology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Jorge Ferreira
- Pulmonology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Joana Amado
- Pulmonology Department, Hospital Pedro Hispano, Matosinhos, Portugal
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10
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Miranda EP, Benfante N, Kunzel B, Nelson CJ, Mulhall JP. A Randomized, Controlled, 3-Arm Trial of Pharmacological Penile Rehabilitation in the Preservation of Erectile Function After Radical Prostatectomy. J Sex Med 2021; 18:423-429. [PMID: 33303389 PMCID: PMC8519168 DOI: 10.1016/j.jsxm.2020.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/28/2020] [Accepted: 10/29/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although the concept of penile rehabilitation after radical prostatectomy (RP) has been advocated for decades, there is little definitive evidence regarding its utility or the best strategy to optimize patient outcomes. AIM The goal of this study is to analyze the ability of 3 different pharmacological strategies to preserve the ability of men to achieve spontaneous (non-medication assisted) erections after bilateral nerve-sparing RP. METHODS This IRB- and FDA-approved study studied penile rehabilitation in a 3-arm fashion with a target enrollment of 200 patients. (i) Control arm: nightly placebo with sildenafil 100 mg on demand for sexual relations (up to 6 pills/month); (ii) nightly sildenafil arm: nightly sildenafil 50 mg and sildenafil 100 mg on demand for sexual relations (up to 6 pills/month); (iii) combination therapy arm: nightly sildenafil 50 mg (5 nights/week) plus intracavernosal injections twice/week. Inclusion criteria included bilateral nerve-sparing surgery, normal serum total testosterone, and good preoperative baseline erectile function as measured by the erectile function domain score of the IIEF (EFD) (≥24). Patients were followed with a medication use diary and the IIEF questionnaire at 6 weeks, 3 m, 6 m, 12 m, 18 m and 24 m. OUTCOMES A difference was seen in the IIEF-EFD scores between the 3 groups at 24 months after RP. Secondary end points include the time to return of spontaneous functional erections, the time for patients to respond to oral erectogenic therapy, and the proportion of patients who have normalization of their IIEF-EFD scores. RESULTS The study was interrupted because of failure to recruit the target study population in a reasonable timeframe. A total of 76 subjects with median age of 57 (IQR: 51, 63) years and mean IIEF-EFD of 29 (IQR: 27, 30) were initially randomized, but at 24 months, the sample sizes by group were (i) n = 4; (ii) n = 18; and (iii) n = 10, with median IIEF-EFD 24 (IQR: 18, 28), 24 (IQR: 18, 28), and 21 (IQR: 9, 26), respectively. There was no statistical difference among the groups in the final analysis. CLINICAL IMPLICATIONS Definitive evidence for the ability of different pharmacological rehabilitation strategies to improve long-term EF outcomes might never be available. STRENGTHS & LIMITATIONS This was a well-designed randomized and 3-arm designed trial intended to provide decisive evidence regarding the utility of penile rehabilitation. Failure to recruit the target population is the main limitation. CONCLUSION The limited number of patients in the present trial precludes definitive interpretation. However, results indicate how challenging it is to conduct true rehabilitation studies. Miranda EP, Benfante N, Kunzel B, et al. A Randomized, Controlled, 3-Arm Trial of Pharmacological Penile Rehabilitation in the Preservation of Erectile Function After Radical Prostatectomy. J Sex Med 2021;18:423-429.
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Affiliation(s)
- Eduardo P Miranda
- Sexual & Reproductive Medicine Program, Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole Benfante
- Sexual & Reproductive Medicine Program, Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brian Kunzel
- Sexual & Reproductive Medicine Program, Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian J Nelson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John P Mulhall
- Sexual & Reproductive Medicine Program, Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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11
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Patson N, Mukaka M, Otwombe KN, Kazembe L, Mathanga DP, Mwapasa V, Kabaghe AN, Eijkemans MJC, Laufer MK, Chirwa T. Systematic review of statistical methods for safety data in malaria chemoprevention in pregnancy trials. Malar J 2020; 19:119. [PMID: 32197619 PMCID: PMC7085184 DOI: 10.1186/s12936-020-03190-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 03/12/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Drug safety assessments in clinical trials present unique analytical challenges. Some of these include adjusting for individual follow-up time, repeated measurements of multiple outcomes and missing data among others. Furthermore, pre-specifying appropriate analysis becomes difficult as some safety endpoints are unexpected. Although existing guidelines such as CONSORT encourage thorough reporting of adverse events (AEs) in clinical trials, they provide limited details for safety data analysis. The limited guidelines may influence suboptimal analysis by failing to account for some analysis challenges above. A typical example where such challenges exist are trials of anti-malarial drugs for malaria prevention during pregnancy. Lack of proper standardized evaluation of the safety of antimalarial drugs has limited the ability to draw conclusions about safety. Therefore, a systematic review was conducted to establish the current practice in statistical analysis for preventive antimalarial drug safety in pregnancy. METHODS The search included five databases (PubMed, Embase, Scopus, Malaria in Pregnancy Library and Cochrane Central Register of Controlled Trials) to identify original English articles reporting Phase III randomized controlled trials (RCTs) on anti-malarial drugs for malaria prevention in pregnancy published from January 2010 to July 2019. RESULTS Eighteen trials were included in this review that collected multiple longitudinal safety outcomes including AEs. Statistical analysis and reporting of the safety outcomes in all the trials used descriptive statistics; proportions/counts (n = 18, 100%) and mean/median (n = 2, 11.1%). Results presentation included tabular (n = 16, 88.9%) and text description (n = 2, 11.1%). Univariate inferential methods were reported in most trials (n = 16, 88.9%); including Chi square/Fisher's exact test (n = 12, 66.7%), t test (n = 2, 11.1%) and Mann-Whitney/Wilcoxon test (n = 1, 5.6%). Multivariable methods, including Poisson and negative binomial were reported in few trials (n = 3, 16.7%). Assessment of a potential link between missing efficacy data and safety outcomes was not reported in any of the trials that reported efficacy missing data (n = 7, 38.9%). CONCLUSION The review demonstrated that statistical analysis of safety data in anti-malarial drugs for malarial chemoprevention in pregnancy RCTs is inadequate. The analyses insufficiently account for multiple safety outcomes potential dependence, follow-up time and informative missing data which can compromise anti-malarial drug safety evidence development, based on the available data.
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Affiliation(s)
- Noel Patson
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- University of Malawi, College of Medicine, Blantyre, Malawi
| | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kennedy N Otwombe
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Kazembe
- Department of Biostatistics, University of Namibia, Windhoek, Namibia
| | - Don P Mathanga
- University of Malawi, College of Medicine, Blantyre, Malawi
| | - Victor Mwapasa
- University of Malawi, College of Medicine, Blantyre, Malawi
| | | | - Marinus J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland, School of Medicine, 685 W. Baltimore St., HSF-1 Room 480, Baltimore, MD, 21201, USA.
| | - Tobias Chirwa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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12
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Takahashi K, Kogame N, Tomaniak M, Chichareon P, Chang CC, Modolo R, Benit E, Liebetrau C, Janssens L, Ferrario M, Zurakowski A, van Geuns RJ, Dominici M, Huber K, Buszman P, Bolognese L, Tumscitz C, Żmudka K, Aminian A, Vrolix M, Petrov I, Wykrzykowska JJ, de Winter RJ, Hamm C, Steg PG, Onuma Y, Valgimigli M, Windecker S, Vranckx P, Garg S, Serruys PW. Impact of recruitment and retention on all-cause mortality in a large all-comers randomised controlled trial: insights from the GLOBAL LEADERS trial. Clin Res Cardiol 2019; 109:918-929. [PMID: 31828504 DOI: 10.1007/s00392-019-01585-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/28/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Recruitment and retention in trials may bias the results and subsequently complicate their interpretation and validity. The aim of this study is to evaluate the impact of recruitment and retention on all-cause mortality in a large all-comers trial. METHODS The recruitment rate in each investigating center of the GLOBAL LEADERS trial was assessed and the 130 centers were subdivided into low and high recruiters according to the median, with all-cause mortality then compared between the two groups. Vital status was obtained from public records in patients with incomplete follow-up. RESULTS The trial randomized 15,991 (7.86%) of 203,483 eligible patients with percutaneous coronary intervention during the recruitment period, of whom 15,267 (95.47%) completed follow-up, 23 (0.14%) patients withdrew consent and formally requested to be deleted from the database; 183 (1.14%) withdrew consent but only objected to future data collection; 303 (1.89%) discontinued the study; and 215 (1.34%) were lost to follow-up. Vital status was finally obtained in all but 31 patients (99.81%). Patients from low recruiters had a significantly lower all-cause mortality than high ones (2.26% vs. 3.24%; hazard ratio: 0.69; 95% confidence interval: 0.55-0.87; p = 0.002). There was a significant difference in all-cause mortality among the incomplete follow-up groups (log-rank p < 0.001) with a significantly higher mortality in the 183 patients who withdrew consent than those who completed follow-up (7.38% vs. 2.99%, p = 0.002). CONCLUSIONS Recruitment and retention significantly impacted all-cause mortality. Search for vital status through public domains is of paramount importance in the interpretation and validity of large clinical trials.
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Affiliation(s)
- Kuniaki Takahashi
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Norihiro Kogame
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Mariusz Tomaniak
- Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Ply Chichareon
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Chun-Chin Chang
- Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rodrigo Modolo
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Cardiology Division, Department of Internal Medicine, University of Campinas (UNICAMP), Campinas, Brazil
| | - Edouard Benit
- Faculty of Medicine and Life Sciences, Jessa Ziekenhuis, Hasselt University, Hasselt, Belgium
| | | | | | - Maurizio Ferrario
- UOC Cardiologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Robert Jan van Geuns
- Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Medical School, Wilhelminen Hospital, and Sigmund Freud University, Vienna, Austria
| | - Pawel Buszman
- American Heart of Poland, Ustroń, Poland
- Department of Epidemiology and Statistics, Medical University of Silesia, Katowice, Poland
| | | | | | - Krzysztof Żmudka
- Department of Interventional Cardiology, Faculty of Medicine, Jagiellonian University, Kraków, Poland
| | - Adel Aminian
- Centre Hospitalier Universitaire Charleroi, Charleroi, Belgium
| | | | | | - Joanna J Wykrzykowska
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Christian Hamm
- Kerckhoff Heartand, Thorax Center, University of Giessen, Bad Nauheim, Germany
| | - Philippe Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials), Université Paris-Diderot, Paris, France
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway, H91 TK33, Ireland
| | - Marco Valgimigli
- Department of Cardiology, University of Bern, Inselspital, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, University of Bern, Inselspital, Bern, Switzerland
| | - Pascal Vranckx
- Faculty of Medicine and Life Sciences, Jessa Ziekenhuis, Hasselt University, Hasselt, Belgium
| | - Scot Garg
- Royal Blackburn Hospital, Blackburn, UK
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway, H91 TK33, Ireland.
- Imperial College London, London, UK.
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