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Granholm A, Lange T, Harhay MO, Jensen AKG, Perner A, Møller MH, Kaas-Hansen BS. Effects of duration of follow-up and lag in data collection on the performance of adaptive clinical trials. Pharm Stat 2024; 23:138-150. [PMID: 37837271 PMCID: PMC10935606 DOI: 10.1002/pst.2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/07/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023]
Abstract
Different combined outcome-data lags (follow-up durations plus data-collection lags) may affect the performance of adaptive clinical trial designs. We assessed the influence of different outcome-data lags (0-105 days) on the performance of various multi-stage, adaptive trial designs (2/4 arms, with/without a common control, fixed/response-adaptive randomisation) with undesirable binary outcomes according to different inclusion rates (3.33/6.67/10 patients/day) under scenarios with no, small, and large differences. Simulations were conducted under a Bayesian framework, with constant stopping thresholds for superiority/inferiority calibrated to keep type-1 error rates at approximately 5%. We assessed multiple performance metrics, including mean sample sizes, event counts/probabilities, probabilities of conclusiveness, root mean squared errors (RMSEs) of the estimated effect in the selected arms, and RMSEs between the analyses at the time of stopping and the final analyses including data from all randomised patients. Performance metrics generally deteriorated when the proportions of randomised patients with available data were smaller due to longer outcome-data lags or faster inclusion, that is, mean sample sizes, event counts/probabilities, and RMSEs were larger, while the probabilities of conclusiveness were lower. Performance metric impairments with outcome-data lags ≤45 days were relatively smaller compared to those occurring with ≥60 days of lag. For most metrics, the effects of different outcome-data lags and lower proportions of randomised patients with available data were larger than those of different design choices, for example, the use of fixed versus response-adaptive randomisation. Increased outcome-data lag substantially affected the performance of adaptive trial designs. Trialists should consider the effects of outcome-data lags when planning adaptive trials.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, PAIR (Palliative and Advanced Illness Research) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Skov Kaas-Hansen
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Garioud ALDB, Andersen LPK, Jensen AKG, Do HQ, Jakobsen JC, Holst LB, Rasmussen LS, Afshari A. Intravenous MELAtonin for prevention of Postoperative Agitation and Emergence Delirium in children (MELA-PAED): A protocol and statistical analysis plan for a randomized clinical trial. Acta Anaesthesiol Scand 2024; 68:280-286. [PMID: 37904610 DOI: 10.1111/aas.14342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/03/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Emergence agitation and delirium in children remain a common clinical challenge in the post-anesthetic care unit. Preoperative oral melatonin has been suggested as an effective preventive drug with a favorable safety profile. The oral bioavailability of melatonin, however, is low. Therefore, the MELA-PAED trial aims to investigate the efficacy and safety of intraoperative intravenous melatonin for the prevention of emergence agitation in pediatric surgical patients. METHODS MELA-PAED is a randomized, double-blind, parallel two-arm, multi-center, superiority trial comparing intravenous melatonin with placebo. Four hundred participants aged 1-6 years will be randomized 1:1 to either the intervention or placebo. The intervention consists of intravenous melatonin 0.15 mg/kg administered approximately 30 min before the end of surgery. Participants will be monitored in the post-anesthetic care unit (PACU), and the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS) will be performed on days 1, 7, and 14 after the intervention. Serious Adverse Events (SAE) will be assessed up to 30 days after the intervention. RESULTS The primary outcome is the incidence of emergence agitation, assessed dichotomously as any Watcha score >2 during the participant's stay in the post-anesthetic care unit. Secondary outcomes are opioid consumption in the post-anesthetic care unit and adverse events. Exploratory outcomes include SAEs, postoperative pain, postoperative nausea and vomiting, and time to awakening, to first oral intake, and to discharge readiness. CONCLUSION The MELA-PAED trial investigates the efficacy of intravenous intraoperative melatonin for the prevention of emergence agitation in pediatric surgical patients. Results may provide further knowledge concerning the use of melatonin in pediatric perioperative care.
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Affiliation(s)
- Anne Louise de Barros Garioud
- Department of Anesthesiology, Juliane Marie Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars Peter Kloster Andersen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Hien Quoc Do
- Department of Anesthesiology, Juliane Marie Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Lars Broksø Holst
- Department of Anesthesiology, Juliane Marie Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | | | - Arash Afshari
- Department of Anesthesiology, Juliane Marie Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kaas-Hansen BS, Kjaer MBN, Møller MH, Jensen AKG, Larsen ME, Cuthbertson BH, Perner A, Granholm A. Health-related quality of life trajectories in critical illness: Protocol for a Monte Carlo simulation study. Acta Anaesthesiol Scand 2024; 68:122-129. [PMID: 37650374 DOI: 10.1111/aas.14324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/12/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Health-related quality of life (HRQoL) is a patient-centred outcome increasingly used as a secondary outcome in critical care research. It may cover several important dimensions of clinical status in intensive care unit (ICU) patients that arguably elude other more easily quantified outcomes such as mortality. Poor associations with harder outcomes, conflicting data on HRQoL in critically ill compared to the background population, and paradoxical effects on HRQoL and mortality complicate the current operationalisation in critical care trials. This protocol outlines a simulation study that will gauge if the areas under the HRQoL trajectories could be a viable alternative. METHODS We will gauge the behaviour of the proposed HRQoL operationalisation through Monte Carlo simulations, under clinical scenarios that reflect a broad critical care population eligible for inclusion in a large pragmatic trial. We will simulate 15,360 clinical scenarios based on a full factorial design with the following seven simulation parameters: number of patients per arm, relative mortality reduction in the interventional arm, acceleration of HRQoL improvement in the interventional arm, the relative improvement in final HRQoL in the interventional arm, dampening effect of mortality on HRQoL values at discharge from the ICU, proportion of so-called mortality benefiters in the interventional arm and mortality trajectory shape. For each clinical scenario, we will simulate 100,000 two-arm trials with 1:1 randomisation. HRQoL will be sampled fortnightly after ICU discharge. Outcomes will include HRQoL in survivors and all patients at the end of follow-up; mean areas under the HRQoL trajectories in both arms; and mean difference between areas under the HRQoL trajectories and single-sampled HRQoLs at the end of follow-up. DISCUSSION In the outlined simulation study, we aim to assess whether the area under the HRQoL trajectory curve could be a candidate for reconciling the seemingly paradoxical effects on improved mortality and reduced HRQoL while remaining sensitive to early or accelerated improvement in patient outcomes. The resultant insights will inform subsequent methodological work on prudent collection and statistical analysis of such data from real critically ill patients.
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Affiliation(s)
- Benjamin Skov Kaas-Hansen
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Deparment of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Deparment of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mia Esta Larsen
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Brian H Cuthbertson
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
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Granholm A, Schjørring OL, Jensen AKG, Kaas-Hansen BS, Munch MW, Klitgaard TL, Crescioli E, Kjaer MBN, Strøm T, Lange T, Perner A, Rasmussen BS, Møller MH. Association between days alive without life support/out of hospital and health-related quality of life. Acta Anaesthesiol Scand 2023; 67:762-771. [PMID: 36915265 DOI: 10.1111/aas.14231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Trials in critically ill patients increasingly focus on days alive without life support (DAWOLS) or days alive out of hospital (DAOOH) and health-related quality of life (HRQoL). DAWOLS and DAOOH convey more information than mortality and are simpler and faster to collect than HRQoL. However, whether these outcomes are associated with HRQoL is uncertain. We thus aimed to assess the associations between DAWOLS and DAOOH and long-term HRQoL. METHODS Secondary analysis of the COVID STEROID 2 trial including adults with COVID-19 and severe hypoxaemia and the Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU) trial including adult intensive care unit patients with acute hypoxaemic respiratory failure. Associations between DAWOLS and DAOOH at day 28 and 90 and long-term HRQoL (after 6 or 12 months) using the EuroQol 5-dimension 5-level survey (EQ VAS and EQ-5D-5L index values) were assessed using flexible models and evaluated using measures of fit and prediction adequacy in both datasets (comprising internal performance and external validation), non-parametric correlation coefficients and graphical presentations. RESULTS We found no strong associations between DAWOLS or DAOOH and HRQoL in survivors at HRQoL-follow-up (615 and 1476 patients, respectively). There was substantial variability in outcomes, and predictions from the best fitted models were poor both internally and externally in the other trial dataset, which also showed inadequate calibration. Moderate associations were found when including non-survivors, although predictions remained uncertain and calibration inadequate. CONCLUSION DAWOLS and DAOOH were poorly associated with HRQoL in adult survivors of severe or critical illness included in the COVID STEROID 2 and HOT-ICU trials.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Benjamin Skov Kaas-Hansen
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Marie Warrer Munch
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Thomas Lass Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Elena Crescioli
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maj-Brit Nørregaard Kjaer
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine, Odense University Hospital, Odense, Denmark
- Department of Anaesthesia and Critical Care Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Odense, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Granholm A, Kaas-Hansen BS, Lange T, Munch MW, Harhay MO, Zampieri FG, Perner A, Møller MH, Jensen AKG. Use of days alive without life support and similar count outcomes in randomised clinical trials - an overview and comparison of methodological choices and analysis methods. BMC Med Res Methodol 2023; 23:139. [PMID: 37316785 DOI: 10.1186/s12874-023-01963-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Days alive without life support (DAWOLS) and similar outcomes that seek to summarise mortality and non-mortality experiences are increasingly used in critical care research. The use of these outcomes is challenged by different definitions and non-normal outcome distributions that complicate statistical analysis decisions. METHODS We scrutinized the central methodological considerations when using DAWOLS and similar outcomes and provide a description and overview of the pros and cons of various statistical methods for analysis supplemented with a comparison of these methods using data from the COVID STEROID 2 randomised clinical trial. We focused on readily available regression models of increasing complexity (linear, hurdle-negative binomial, zero-one-inflated beta, and cumulative logistic regression models) that allow comparison of multiple treatment arms, adjustment for covariates and interaction terms to assess treatment effect heterogeneity. RESULTS In general, the simpler models adequately estimated group means despite not fitting the data well enough to mimic the input data. The more complex models better fitted and thus better replicated the input data, although this came with increased complexity and uncertainty of estimates. While the more complex models can model separate components of the outcome distributions (i.e., the probability of having zero DAWOLS), this complexity means that the specification of interpretable priors in a Bayesian setting is difficult. Finally, we present multiple examples of how these outcomes may be visualised to aid assessment and interpretation. CONCLUSIONS This summary of central methodological considerations when using, defining, and analysing DAWOLS and similar outcomes may help researchers choose the definition and analysis method that best fits their planned studies. TRIAL REGISTRATION COVID STEROID 2 trial, ClinicalTrials.gov: NCT04509973, ctri.nic.in: CTRI/2020/10/028731.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, DK-2100, Copenhagen, Denmark.
| | - Benjamin Skov Kaas-Hansen
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, DK-2100, Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Marie Warrer Munch
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, DK-2100, Copenhagen, Denmark
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Fernando G Zampieri
- HCor Research Institute, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Alberta, Canada
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, DK-2100, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, DK-2100, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Granholm A, Kaas-Hansen BS, Lange T, Schjørring OL, Andersen LW, Perner A, Jensen AKG, Møller MH. An overview of methodological considerations regarding adaptive stopping, arm dropping, and randomization in clinical trials. J Clin Epidemiol 2023; 153:45-54. [PMID: 36400262 DOI: 10.1016/j.jclinepi.2022.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 10/17/2022] [Accepted: 11/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Adaptive features may increase flexibility and efficiency of clinical trials, and improve participants' chances of being allocated to better interventions. Our objective is to provide thorough guidance on key methodological considerations for adaptive clinical trials. METHODS We provide an overview of key methodological considerations for clinical trials employing adaptive stopping, adaptive arm dropping, and response-adaptive randomization. We cover pros and cons of different decisions and provide guidance on using simulation to compare different adaptive trial designs. We focus on Bayesian multi-arm adaptive trials, although the same general considerations apply to frequentist adaptive trials. RESULTS We provide guidance on 1) interventions and possible common control, 2) outcome selection, follow-up duration and model choice, 3) timing of adaptive analyses, 4) decision rules for adaptive stopping and arm dropping, 5) randomization strategies, 6) performance metrics, their prioritization, and arm selection strategies, and 7) simulations, assessment of performance under different scenarios, and reporting. Finally, we provide an example using a newly developed R simulation engine that may be used to evaluate and compare different adaptive trial designs. CONCLUSION This overview may help trialists design better and more transparent adaptive clinical trials and to adequately compare them before initiation.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Benjamin Skov Kaas-Hansen
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lars W Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Thysen SM, Møller Jensen A, Vedel JO, da Silva Borges I, Aaby P, Jensen AKG, Benn CS, Fisker AB. Can BCG vaccination at first health-facility contact reduce early infant mortality? Study protocol for a cluster-randomised trial (CS-BCG). BMJ Open 2022; 12:e063872. [PMID: 36410811 PMCID: PMC9680145 DOI: 10.1136/bmjopen-2022-063872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Increasing evidence suggests that the BCG vaccine has non-specific effects, altering the susceptibility to non-tuberculous infections. Thus, early BCG vaccination may reduce mortality. BCG is recommended at birth but is often delayed. Vaccination opportunities are missed due to multidose vials not being opened for a few children. We will assess the effect of making BCG available at the first health-facility contact on early infant mortality and morbidity in a rural setting in Guinea-Bissau. METHODS AND ANALYSIS In a cluster-randomised crossover trial, we randomise 23 health centres to two different treatment groups. In half of the health centres, BCG is provided as per current practice; in the remaining health centres, we make BCG available everyday to allow opening a vial of BCG if there is just one eligible child present. The randomisation of centres will be crossed over after 12 months and enrolment will continue for another 12 months.We will use logistic regression models with adjustment for village to assess the effect of making BCG available at the first health-facility contact. The main outcome is non-accidental mortality between day 1 and day 42 after birth. We will adjust for sex, health centre, period (before/after crossover) and level of surveillance (level 1 or level 2). Further analyses include assessment of the effect on hospital admission and a cost-effectiveness evaluation. ETHICS AND DISSEMINATION If BCG vaccination reduces early infant mortality, missed opportunities and delays of vaccinations expose infants in several low-income countries to unnecessary excess mortality risk. The present trial will provide information on the effect of implementing a feasible intervention, where all children receive BCG at their first health-facility contact. Consent is obtained from all pregnant women registered as part of the trial. The results of the study will be published and communicated to the National Institute of Public Health in Guinea-Bissau. TRIAL REGISTRATION NUMBER NCT04658680; Clinicaltrials.gov.
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Affiliation(s)
- Sanne Marie Thysen
- Bandim Health Project, Bissau, Guinea-Bissau
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Center for Clinical Research and Prevention, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Andreas Møller Jensen
- Bandim Health Project, Bissau, Guinea-Bissau
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Julie Odgaard Vedel
- Bandim Health Project, Bissau, Guinea-Bissau
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau
| | | | - Christine Stabell Benn
- Bandim Health Project, Bissau, Guinea-Bissau
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ane Bærent Fisker
- Bandim Health Project, Bissau, Guinea-Bissau
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Olsen MH, Jensen AKG, Dankiewicz J, Skrifvars MB, Reinikainen M, Tiainen M, Saxena M, Aneman A, Gluud C, Ullén S, Nielsen N, Jakobsen JC. Interactions in the 2×2×2 factorial randomised clinical STEPCARE trial and the potential effects on conclusions: a protocol for a simulation study. Trials 2022; 23:889. [PMID: 36273179 PMCID: PMC9587583 DOI: 10.1186/s13063-022-06796-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/27/2022] [Indexed: 11/28/2022] Open
Abstract
Background
Randomised clinical trials with a factorial design may assess the effects of multiple interventions in the same population. Factorial trials are carried out under the assumption that the trial interventions have no interactions on outcomes. Here, we present a protocol for a simulation study investigating the consequences of different levels of interactions between the trial interventions on outcomes for the future 2×2×2 factorial designed randomised clinical Sedation, TEmperature, and Pressure after Cardiac Arrest and REsuscitation (STEPCARE) trial in comatose patients after out-of-hospital cardiac arrest. Methods By simulating a multisite trial with 50 sites and 3278 participants, and a presumed six-month all-cause mortality of 60% in the control population, we will investigate the validity of the trial results with different levels of interaction effects on the outcome. The primary simulation outcome of the study is the risks of type-1 and type-2 errors in the simulated scenarios, i.e. at what level of interaction is the desired alpha and beta level exceeded. When keeping the overall risk of type-1 errors ≤ 5% and the risk of type-2 errors ≤ 10%, we will quantify the maximum interaction effect we can accept if the planned sample size is increased by 5% to take into account possible interaction between the trial interventions. Secondly, we will assess how interaction effects influence the minimal detectable difference we may confirm or reject to take into account 5% (small interaction effect), 10% (moderate), or 15% (large) positive interactions in simulations with no ‘true’ intervention effect (type-1 errors) and small (5%), moderate (10%), or large negative interactions (15%) in simulations with ‘true’ intervention effects (type-2 errors). Moreover, we will investigate how much the sample size must be increased to account for a small, moderate, or large interaction effects. Discussion This protocol for a simulation study will inform the design of a 2×2×2 factorial randomised clinical trial of how potential interactions between the assessed interventions might affect conclusions. Protocolising this simulation study is important to ensure valid and unbiased results. Trial registration Not relevant
Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06796-7.
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Affiliation(s)
- Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. .,Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Josef Dankiewicz
- Department of Clinical Sciences, Cardiology, Lund University, Skåne University Hospital Lund, Lund, Sweden
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Marjaana Tiainen
- Department of Anesthesiology, Intensive Care, and Pain Medicine, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Manoj Saxena
- Critical Care Division, the George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Clinical School, University of New South Wales, Sydney, Australia
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Susann Ullén
- Clinical Studies Sweden - Forum South, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesiology and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Holt A, Blanche P, Jensen AKG, Nouhravesh N, Rajan D, Jensen MH, El-Sheikh M, Schjerning AM, Schou M, Gislason G, Torp-Pedersen C, McGettigan P, Lamberts M. Adverse Events Associated With Coprescription of Phosphodiesterase Type 5 Inhibitors and Oral Organic Nitrates in Male Patients With Ischemic Heart Disease : A Case-Crossover Study. Ann Intern Med 2022; 175:774-782. [PMID: 35436155 DOI: 10.7326/m21-3445] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Concomitant use of oral organic nitrates (nitrates) and phosphodiesterase type 5 (PDE5) inhibitors is contraindicated. OBJECTIVE To measure temporal trends in the coprescription of nitrates and PDE5 inhibitors and to measure the association between cardiovascular outcomes and the coprescription of nitrates with PDE5 inhibitors. DESIGN Case-crossover design. SETTING Nationwide study of Danish patients from 2000 to 2018. PATIENTS Male patients with International Classification of Diseases, 10th Revision (ICD-10) codes for ischemic heart disease (IHD), including those who had a continuing prescription for nitrates and a new, filled prescription for PDE5 inhibitors. MEASUREMENTS Two composite outcomes were measured: 1) cardiac arrest, shock, myocardial infarction, ischemic stroke, or acute coronary arteriography and 2) syncope, angina pectoris, or drug-related adverse event. RESULTS From 2000 to 2018, 249 541 male patients with IHD were identified. Of these, 42 073 patients had continuing prescriptions for nitrates. During this period, the prescription rate for PDE5 inhibitors in patients with IHD who were taking nitrates increased from an average of 0.9 prescriptions (95% CI, 0.5 to 1.2 prescriptions) per 100 persons per year in 2000 to 19.5 prescriptions (CI, 18.0 to 21.1 prescriptions) in 2018. No statistically significant association was found between the coprescription of nitrates with PDE5 inhibitors and the risk for either composite outcome (odds ratio [OR], 0.58 [CI, 0.28 to 1.13] for the first outcome and OR, 0.73 [CI, 0.40 to 1.32] for the second outcome). LIMITATION An assumption was made that concurrently filled prescriptions for nitrates and PDE5 inhibitors equaled concomitant use. CONCLUSION From 2000 to 2018, the use of PDE5 inhibitors increased 20-fold among Danish patients with IHD who were taking nitrates. A statistically significant association between concomitant use of these medications and cardiovascular adverse events could not be identified. PRIMARY FUNDING SOURCE Ib Mogens Kristiansens Almene Fond and Helsefonden.
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Affiliation(s)
- Anders Holt
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark (A.H., N.N., D.R., M.H.J., M.E., M.S., M.L.)
| | - Paul Blanche
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark (P.B., A.K.G.J.)
| | | | - Nina Nouhravesh
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark (A.H., N.N., D.R., M.H.J., M.E., M.S., M.L.)
| | - Deepthi Rajan
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark (A.H., N.N., D.R., M.H.J., M.E., M.S., M.L.)
| | - Mads Hashiba Jensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark (A.H., N.N., D.R., M.H.J., M.E., M.S., M.L.)
| | - Mohammed El-Sheikh
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark (A.H., N.N., D.R., M.H.J., M.E., M.S., M.L.)
| | - Anne-Marie Schjerning
- Department of Cardiology, Zealand University Hospital, Roskilde, and The Danish Heart Foundation, Copenhagen, Denmark (A.S.)
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark (A.H., N.N., D.R., M.H.J., M.E., M.S., M.L.)
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, and The Danish Heart Foundation, Copenhagen, Denmark (G.G.)
| | - Christian Torp-Pedersen
- Department of Clinical Research, North Zealand Hospital, Hillerød, and Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark (C.T.)
| | - Patricia McGettigan
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (P.M.)
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark (A.H., N.N., D.R., M.H.J., M.E., M.S., M.L.)
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10
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Granholm A, Schjørring OL, Jensen AKG, Kaas‐Hansen BS, Munch MW, Klitgaard TL, Crescioli E, Kjær MN, Strøm T, Perner A, Rasmussen BS, Møller MH. Health-related quality of life and days alive without life support or out of hospital: Protocol. Acta Anaesthesiol Scand 2022; 66:295-301. [PMID: 34811741 DOI: 10.1111/aas.14001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mortality is often the primary outcome in randomised clinical trials (RCTs) conducted in critically ill patients. Due to increased awareness on survivors after critical illness and outcomes other than mortality, health-related quality of life (HRQoL) and days alive without life support (DAWOLS) or days alive and out of hospital (DAAOOH) are increasingly being used. DAWOLS and DAAOOH convey more information than mortality, are easier to collect than HRQoL, and are usually assessed at earlier time points, which may be preferable in some situations. However, the associations between DAWOLS-DAAOOH and HRQoL are uncertain. METHODS We will assess associations between DAWOLS-DAAOOH at day 28 and 90 (independent variables/predictors) and HRQoL assessed using the EuroQol EQ-5D-5L questionnaire (EQ-VAS and EQ-5D-5L index values) at 6 or 12 months (dependent variables) in two RCTs: the COVID STEROID 2 RCT conducted in adult patients with COVID-19 and severe hypoxaemia and the Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU) RCT conducted in adult intensive care patients with acute hypoxaemic respiratory failure. We will describe associations using best-fitting fractional polynomial transformations separately in each dataset, with the resulting models presented and assessed in both datasets graphically and using measures of fit and prediction adequacy (i.e., internal performance and external validation). We will use multiple imputation if missingness exceeds 5%. DISCUSSION The outlined study will provide important knowledge on the associations between DAWOLS-DAAOOH and HRQoL in adult critically ill patients, which may help researchers and clinical trialists prioritise and select outcomes in future RCTs conducted in this population.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Olav Lilleholt Schjørring
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Benjamin Skov Kaas‐Hansen
- Section of Biostatistics, Department of Public Health University of Copenhagen Copenhagen Denmark
- Clinical Pharmacology Unit Zealand University Hospital Roskilde Denmark
| | - Marie Warrer Munch
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Thomas Lass Klitgaard
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Elena Crescioli
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Maj‐Brit Nørregaard Kjær
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine Odense University Hospital Odense Denmark
- Department of Anaesthesia and Critical Care Medicine Hospital Sønderjylland, University Hospital of Southern Denmark Odense Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
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11
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Holt A, Blanche P, Jensen AKG, Nouhravesh N, Rajan D, Jensen MH, El-Sheikh M, Schjerning AM, Schou M, Torp-Pedersen C, Gislason GH, McGettigan P, Lamberts M. Usage and risk with phosphodiesterase type 5 inhibitors in male patients with chronic ischemic heart disease on oral organic nitrates. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Combining oral organic nitrates (OON) with phosphodiesterase type 5 (PDE5) inhibitors is contraindicated. Growing and liberal use of PDE5 inhibitors for erectile dysfunction among patients with ischemic heart disease (IHD) could pose serious health consequences especially among patients with IHD on OON.
Purpose
We hypothesize that concomitant prescription of OON and PDE5 inhibitors is prevalent and has increased in recent years, and further that possible co-exposure could be associated with an increased risk of ischemic stroke, myocardial infarction (MI) or acute coronary angiography (CAG).
Methods
During 2000–2018, we included all male patients with history of IHD between 18 and 85 years of age from nationwide Danish health registers. Patients with a history of pulmonary hypertension were excluded and not followed up afterwards if they developed the condition during follow-up. From this cohort, we identified an OON treated subgroup defined by two consecutively redeemed prescriptions of OON within 180 days from each other. Further, to become a case or control, patients had to redeem a prescription of OON within 180 days prior to the event or corresponding date among controls.
Temporal trends during 2001–2018 of PDE5 inhibitor use were calculated among all male patients with IHD and the subgroup on OON. Among OON treated patients, we examined associations between PDE5 inhibitor use and risk of ischemic stroke, MI or CAG using a case-crossover design where each individual serves as his/her own control thereby controlling for time-invariant confounding. The case-crossover design compares an individual's exposure in an index period just before the event occurred to a reference period prior to the index period. We investigated periods of varying length (7, 14, 21 and 28 days). To account for possible temporal trends in the use of PDE5 inhibitors, we also conducted a case-time-control analysis using a control group matched on age and calendar year.
Results
We identified 249,541 male patients with IHD (median age 65 years [IQR 56–73]), and a subgroup of 42,073 (17%) on OON treatment (median age 70 years [IQR 62–77]). From 2001 to 2018, the use of PDE5 inhibitors saw a 6-fold increase among all male IHD patients and a 10-fold rise in the subgroup on OON (Figure 1). The risk of ischemic stroke, MI or CAG following exposure to PDE5 inhibitors was not increased in the OON subgroup in neither the case-crossover nor the case-time-control analyses (Figure 2).
Conclusions
The use of PDE5 inhibitors has increased 6-fold since 2001 among male patients with IHD, and 10-fold among patients on OON–notwithstanding an established absolute contraindication. However, we did not find any evidence of an increased risk of ischemic stroke, MI or acute CAG following exposure to PDE5 inhibitors in the OON subgroup. This suggests that patients on OON are adequately informed and comply with the recommended pause in OON medication prior to PDE5 inhibitor use.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Ib Mogens Kristiansens Almene FondandHelsefonden
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Affiliation(s)
- A Holt
- Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - P Blanche
- University of Copenhagen, Section of Biostatistics, Copenhagen, Denmark
| | - A K G Jensen
- University of Copenhagen, Section of Biostatistics, Copenhagen, Denmark
| | - N Nouhravesh
- Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - D Rajan
- Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - M H Jensen
- Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - M El-Sheikh
- Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - A M Schjerning
- Zealand University Hospital, Department of Cardiology, Roskilde, Denmark
| | - M Schou
- Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - C Torp-Pedersen
- Nordsjaellands Hospital, Department of Clinical Research, Hilleroed, Denmark
| | - G H Gislason
- Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - P McGettigan
- William Harvey Research Institute, Department of Pharmacology, London, United Kingdom
| | - M Lamberts
- Herlev and Gentofte Hospital, Copenhagen, Denmark
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12
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Granholm A, Kaas‐Hansen BS, Kjær MN, Anthon CT, Sivapalan P, Schjørring OL, Andersen LW, Mathiesen O, Strøm T, Jensen AKG, Perner A, Møller MH. Patient-important outcomes other than mortality in recent ICU trials: Protocol for a scoping review. Acta Anaesthesiol Scand 2021; 65:1002-1007. [PMID: 34089522 DOI: 10.1111/aas.13937] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/29/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Randomised clinical trials (RCTs) conducted in intensive care units (ICUs) frequently focus on all-cause mortality, but other patient-important outcomes are increasingly used and recommended. Their use, however, is not straightforward: choices and definitions, operationalisation of death, handling of missing data, choice of effect measures, and statistical analyses for these outcomes vary greatly. METHODS We will conduct a scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. We will search 10 selected general and speciality journals for RCTs conducted in adult ICU patients from 2018 and onwards reporting at least 1 patient-important outcome other than mortality (including days alive without life support/days alive and out of hospital-type outcomes, health-related quality of life, functional/cognitive/neurological outcomes, and other general patient-important outcomes). We will summarise data on outcome measures and definitions, assessment time points, proportions and handling of death, proportions and handling of missing data, and effect measures and statistical methods used for analysis. DISCUSSION The outlined scoping review will provide an overview of choices, definitions and handling of patient-important outcomes other than mortality in contemporary RCTs conducted in adult ICU patients. This may guide discussions with patients and relatives, the design of future RCTs, and research on optimal outcome choices and handling.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Benjamin Skov Kaas‐Hansen
- NNF Center for Protein Research University of Copenhagen Copenhagen Denmark
- Clinical Pharmacology Unit Zealand University Hospital Roskilde Denmark
| | | | - Carl Thomas Anthon
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Praleene Sivapalan
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Lars W. Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
- Department of Anesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
- Prehospital Emergency Medical Services Central Denmark Region Aarhus Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology Zealand University Hospital Køge Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine Odense University Hospital Odense Denmark
- Department of Anaesthesia and Critical Care Medicine Hospital Sønderjylland, University Hospital of Southern Denmark Odense Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
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13
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Clipet-Jensen C, Andersen A, Jensen AKG, Aaby P, Zaman K. Out-of-Sequence Vaccinations With Measles Vaccine and Diphtheria-Tetanus-Pertussis Vaccine: A Reanalysis of Demographic Surveillance Data From Rural Bangladesh. Clin Infect Dis 2021; 72:1429-1436. [PMID: 32185375 DOI: 10.1093/cid/ciaa291] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 03/16/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Due to delays in vaccinations, diphtheria-tetanus-whole-cell-pertussis (DTP) is often given with or after measles vaccine (MV)-out of sequence. We reanalyzed data from Matlab, Bangladesh, to examine how administration of MV and DTP out-of-sequence was associated with child survival. METHODS In sum, 36 650 children born between 1986 and 1999 were followed with registration of vaccinations and survival. Controlling for background factors using Cox proportional hazards models, survival was analyzed between 9 and 24 months of age. We measured the mortality rate ratio (MRR) to compare vaccination groups. Oral polio vaccine (OPV) campaigns, which started in 1995, reduced the mortality rate and reduced the difference between vaccination groups. In the main analysis, we therefore censored for OPV campaigns; there were 151 nonaccident deaths before the OPV campaigns. RESULTS Compared with MV administered alone (MV-only), DTP administered with or after MV had MRR 2.20 (1.31-3.70), and DTP-only had MRR 1.78 (1.01-3.11). Compared with MV-only, DTP administered with MV had a female-male MRR 0.56 (0.13-2.38), significantly different to DTP administered after MV, which had MRR 14.83 (1.88-117.1), test of interaction P = .011. Compared with having DTP (no MV) as most recent vaccination, MV-only had a nonaccident MRR of 0.56 (0.32-0.99). CONCLUSION The negative effects of non-live DTP with or after live MV are not explained merely by selection bias. These observations support a live-vaccine-last policy where DTP should not be given with or after MV.
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Affiliation(s)
- Clara Clipet-Jensen
- Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Andreas Andersen
- Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark.,Section of Biostatistics, University of Copenhagen, Denmark
| | - Peter Aaby
- Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark.,Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - K Zaman
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
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14
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Varma A, Aaby P, Thysen SM, Jensen AKG, Fisker AB. Reduction in Short-term Outpatient Consultations After a Campaign With Measles Vaccine in Children Aged 9-59 Months: Substudy Within a Cluster-Randomized Trial. J Pediatric Infect Dis Soc 2020; 9:535-543. [PMID: 32897359 DOI: 10.1093/jpids/piaa091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/14/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND We assessed a measles vaccination campaign's potential short-term adverse events. METHODS In a cluster-randomized trial assessing a measles vaccination campaign's effect on all-cause mortality and hospital admission among children aged 9-59 months in Guinea-Bissau, children received a measles vaccination (intervention) or a health check-up (control). One month to 2 months later, we visited a subgroup of children to ask mothers/guardians about outpatient consultations since enrollment. In log-binomial models, we estimated the relative risk (RR) of nonaccidental outpatient consultations. RESULTS Among 8319 children (4437 intervention/3882 control), 652 nonaccidental outpatient consultations occurred (322 intervention/330 control). The measles vaccination campaign tended to reduce nonaccidental outpatient consultations by 16% (RR, 0.84 [95% confidence interval {CI}, .65-1.11]), especially if caused by respiratory symptoms (RR, 0.68 [95% CI, .42-1.11]). The reduction tended to be larger in children who prior to trial enrollment had a pentavalent vaccination (diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b) as the most recent vaccination (RR, 0.61 [95% CI, .42-.89]) than in children who prior to trial enrollment had a routine measles vaccination as the most recent vaccination (RR, 0.93 [95% CI, .68-1.26]) (P = .04 for interaction). CONCLUSIONS In the short term, a measles vaccination campaign seems not to increase nonaccidental outpatient consultations but may reduce them. CLINICAL TRIALS REGISTRATION NCT03460002.
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Affiliation(s)
- Anshu Varma
- OPEN, University of Southern Denmark, Odense, Denmark.,Indepth Network, Bandim Health Project, Bissau, Guinea-Bissau.,Research Center of Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
| | - Peter Aaby
- OPEN, University of Southern Denmark, Odense, Denmark.,Indepth Network, Bandim Health Project, Bissau, Guinea-Bissau.,Research Center of Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
| | - Sanne Marie Thysen
- OPEN, University of Southern Denmark, Odense, Denmark.,Indepth Network, Bandim Health Project, Bissau, Guinea-Bissau.,Research Center of Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- OPEN, University of Southern Denmark, Odense, Denmark.,Research Center of Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark.,Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Ane Bærent Fisker
- OPEN, University of Southern Denmark, Odense, Denmark.,Indepth Network, Bandim Health Project, Bissau, Guinea-Bissau.,Research Center of Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
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15
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Gehrt L, Rieckmann A, Kiraly N, Jensen AKG, Aaby P, Benn CS, Sørup S. Timeliness of DTaP-IPV-Hib Vaccination and Development of Atopic Dermatitis Between 4 Months and 1 Year of Age-Register-Based Cohort Study. J Allergy Clin Immunol Pract 2020; 9:1520-1528.e8. [PMID: 33011301 DOI: 10.1016/j.jaip.2020.09.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 08/24/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND An Australian study including 4433 children found that delayed Diphtheria-Tetanus-acellular Pertussis-containing vaccination was associated with reduced risk of developing atopic dermatitis (AD) before age 1 year. OBJECTIVE We assessed whether delayed vaccination against diphtheria, tetanus, acellular pertussis, polio, and Haemophilus influenzae type b (Diphtheria, Tetanus, acellular Pertussis - Inactivated Polio vaccine - Haemophilus influenzae type b [DTaP]) was associated with a reduced risk of new cases of AD before age 1 year in Denmark. METHODS We used nationwide registers to follow 883,160 children born in Denmark from 1997 to 2012. Binary regression models adjusting for potential confounding factors were applied to estimate relative risks (adjusted relative risks [aRRs]) of developing AD among children with delayed DTaP vaccination (defined as given 1 month or more after the recommended age) compared with timely vaccinated children. RESULTS Among 143,429 children with a delayed first dose of DTaP, 4,847 (3.4%) developed AD between age 4 months and 1 year, compared with 27,628 (3.7%) among 739,731 children not having delayed DTaP (aRR 0.94; 95% CI, 0.91-0.97). The aRR was 0.94 (95% CI, 0.90-0.99) for children with a delayed second dose, and the aRR was 0.88 (95% CI, 0.82-0.93) when comparing children with delayed first and second doses with all timely vaccinated children. CONCLUSIONS The results support the hypothesis that delayed vaccination with DTaP is associated with reduced risk of developing new cases of AD after age 4 months. The dose-dependent relationship strengthens the evidence of a causal relationship. Some countries are introducing maternal pertussis vaccination and delaying the first dose of DTaP, providing a possibility for further testing the hypothesis.
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Affiliation(s)
- Lise Gehrt
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; OPEN, Open Patient data Explorative Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Andreas Rieckmann
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicholas Kiraly
- Gastro and Food Allergy, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Aksel Karl Georg Jensen
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Peter Aaby
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - Christine Stabell Benn
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; OPEN, Open Patient data Explorative Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
| | - Signe Sørup
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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16
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Madsen AMR, Schaltz-Buchholzer F, Benfield T, Bjerregaard-Andersen M, Dalgaard LS, Dam C, Ditlev SB, Faizi G, Johansen IS, Kofoed PE, Kristensen GS, Loekkegaard ECL, Mogensen CB, Mohamed L, Ostenfeld A, Oedegaard ES, Soerensen MK, Wejse C, Jensen AKG, Nielsen S, Krause TG, Netea MG, Aaby P, Benn CS. Using BCG vaccine to enhance non-specific protection of health care workers during the COVID-19 pandemic: A structured summary of a study protocol for a randomised controlled trial in Denmark. Trials 2020; 21:799. [PMID: 32943115 PMCID: PMC7495402 DOI: 10.1186/s13063-020-04714-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/27/2020] [Indexed: 11/20/2022] Open
Abstract
Objectives: The Bacille Calmette-Guérin (BCG) vaccine against tuberculosis is associated with non- specific protective effects against other infections, and significant reductions in all-cause morbidity and mortality have been reported. We aim to test whether BCG vaccination may reduce susceptibility to and/or the severity of COVID-19 and other infectious diseases in health care workers (HCW) and thus prevent work absenteeism. The primary objective is to reduce absenteeism due to illness among HCW during the COVID-19 pandemic. The secondary objectives are to reduce the number of HCW that are infected with SARS-CoV-2, and to reduce the number of hospital admissions among HCW during the COVID-19 pandemic. Hypothesis: BCG vaccination of HCW will reduce absenteeism by 20% over a period of 6 months. Trial design: Placebo-controlled, single-blinded, randomised controlled trial, recruiting study participants at several geographic locations. The BCG vaccine is used in this study on a different indication than the one it has been approved for by the Danish Medicines Agency, therefore this is classified as a phase III study. Participants: The trial will recruit 1,500 HCW at Danish hospitals. To be eligible for participation, a subject must meet the following criteria: Adult (≥18 years); Hospital personnel working at a participating hospital for more than 22 hours per week. A potential subject who meets any of the following criteria will be excluded from participation in this study:
Known allergy to components of the BCG vaccine or serious adverse events to prior BCG administration Known prior active or latent infection with Mycobacterium tuberculosis (M. tuberculosis) or other mycobacterial species Previous confirmed COVID-19 Fever (>38 C) within the past 24 hours Suspicion of active viral or bacterial infection Pregnancy Breastfeeding Vaccination with other live attenuated vaccine within the last 4 weeks Severely immunocompromised subjects. This exclusion category comprises: a) subjects with known infection by the human immunodeficiency virus (HIV-1) b) subjects with solid organ transplantation c) subjects with bone marrow transplantation d) subjects under chemotherapy e) subjects with primary immunodeficiency f) subjects under treatment with any anti-cytokine therapy within the last year g) subjects under treatment with oral or intravenous steroids defined as daily doses of 10 mg prednisone or equivalent for longer than 3 months h) Active solid or non-solid malignancy or lymphoma within the prior two years Direct involvement in the design or the execution of the BCG-DENMARK-COVID trial
Intervention and comparator: Participants will be randomised to BCG vaccine (BCG-Denmark, AJ Vaccines, Copenhagen, Denmark) or placebo (saline). An adult dose of 0.1 ml of resuspended BCG vaccine (intervention) or 0.1 ml of sterile 0.9% NaCl solution (control) is administered intradermally in the upper deltoid area of the right arm. All participants will receive one injection at inclusion, and no further treatment of study participants will take place. Main outcomes: Main study endpoint: Days of unplanned absenteeism due to illness within 180 days of randomisation. Secondary study endpoints: The cumulative incidence of documented COVID-19 and the cumulative incidence of hospital admission for any reason within 180 days of randomisation. Randomisation: Randomisation will be done centrally using the REDCap tool with stratification by hospital, sex and age groups (+/- 45 years of age) in random blocks of 4 and 6. The allocation ratio is 1:1. Blinding (masking): Participants will be blinded to treatment. The participant will be asked to leave the room while the allocated treatment is prepared. Once ready for injection, vaccine and placebo will look similar, and the participant will not be able to tell the difference. The physicians administering the treatment are not blinded. Numbers to be randomised (sample size): Sample size: N=1,500. The 1,500 participants will be randomised 1:1 to BCG or placebo with 750 participants in each group. Trial Status: Current protocol version 5.1, from July 6, 2020. Recruitment of study participants started on May 18, 2020 and we anticipate having finished recruiting by the end of December 2020. Trial registration: The trial was registered with EudraCT on April 16, 2020, EudraCT number: 2020-001888-90, and with ClinicalTrials.gov on May 1, 2020, registration number NCT04373291. Full protocol: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. Keywords: COVID-19, Randomised controlled trial, Protocol, BCG vaccine, NSEs/Non-specific effects of vaccines, Heterologous effects of vaccines, Health care workers, Pandemic, Immune training.
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Affiliation(s)
- Anne Marie Rosendahl Madsen
- Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark.
| | - Frederik Schaltz-Buchholzer
- Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - Thomas Benfield
- Center of Research & Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre Hospital, Hvidovre, Denmark
| | | | | | - Christine Dam
- Department of Respiratory Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Sisse Bolm Ditlev
- The Copenhagen Center for Translational Research (CCTR), Bispebjerg Hospital, Copenhagen, Denmark
| | - Gulia Faizi
- Department of Medicine, Sydvestjysk Hospital, Esbjerg, Denmark
| | | | | | | | | | | | - Libin Mohamed
- Department of Pediatrics, Lillebaelt Hospital, Kolding, Denmark
| | - Anne Ostenfeld
- Department of Gynaecology and Obstetrics, Nordsjaellands Hospital, Hilleroed, Denmark
| | - Emilie Sundhaugen Oedegaard
- Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - Marcus Kjaer Soerensen
- Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - Christian Wejse
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sebastian Nielsen
- Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | | | - Mihai G Netea
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands.,Department for Genomics & Immunoregulation, Life and Medical Sciences Institute (LIMES), University of Bonn, Bonn, Germany
| | - Peter Aaby
- Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - Christine Stabell Benn
- Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
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Hanifi SMA, Biering-Sørensen S, Jensen AKG, Aaby P, Bhuiya A. Penta is associated with an increased female-male mortality ratio: cohort study from Bangladesh. Hum Vaccin Immunother 2020; 17:197-204. [PMID: 32573310 DOI: 10.1080/21645515.2020.1763084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Diphtheria-tetanus-pertussis (DTP) vaccine may be associated with excess female deaths. There are few studies of possible nonspecific effects of the DTP-containing vaccine Penta (DTP-hepatitis B-Haemophilus influenzae type b). We therefore investigated whether Penta vaccinations were associated with excess female deaths in rural Bangladesh. Between June 29, 2011 and April 20, 2016, we examined the mortality rates of 7644 children followed between 6 weeks and 9 months of age. We analyzed mortality using crude mortality rate ratio (MRR) and age-adjusted MRR (aMRR) from a Cox proportional hazards model. Mortality was analyzed according to sex, number of doses of Penta, and the order in which BCG and Penta were administered. During follow-up, 43 children died. For children who were only BCG vaccinated (BCG-only), the adjusted F/M MRR was 0.47 (0.09-2.48). However, among children who had Penta as their most recent vaccination, the adjusted F/M MRR was 9.91 (1.16-84.44). Hence, the adjusted F/M MRR differed significantly for BCG-only and for Penta as the most recent administered vaccination. Although the mortality rate was low in rural Bangladesh, there was a marked difference between adjusted F/M MRR's for children vaccinated with BCG-only compared with children where Penta was the most recent administered vaccination. Although usually ascribed to differential treatment and access to care, DTP-containing vaccines may be part of the explanation for the excessive female mortality reported in some regions.
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Affiliation(s)
- Syed Manzoor Ahmed Hanifi
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and OPEN, Institute of Clinical Research, University of Southern Denmark , Odense, Denmark
| | - Sofie Biering-Sørensen
- Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut , Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- cResearch Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut , Copenhagen, Denmark.,Denmark and Section of Biostatistics, University of Copenhagen , Copenhagen, Denmark
| | - Peter Aaby
- Bandim Health Project, INDEPTH Network , Apartado 861, Guinea-Dissau
| | - Abbas Bhuiya
- Former Deputy Executive Director, icddr,b , Dhaka, Bangladesh
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18
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Berendsen MLT, Øland CB, Bles P, Jensen AKG, Kofoed PE, Whittle H, de Bree LCJ, Netea MG, Martins C, Benn CS, Aaby P. Maternal Priming: Bacillus Calmette-Guérin (BCG) Vaccine Scarring in Mothers Enhances the Survival of Their Child With a BCG Vaccine Scar. J Pediatric Infect Dis Soc 2020; 9:166-172. [PMID: 30715451 DOI: 10.1093/jpids/piy142] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 01/16/2019] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND HYPOTHESIS Maternal priming might enhance the beneficial nonspecific effects (NSEs) of live measles vaccination (MV). Children with a bacillus Calmette-Guérin (BCG) vaccine scar have a lower mortality rate than those without a scar that is not explained by protection against tuberculosis. We examined the hypothesis that BCG scarring would have a stronger effect on a child if the mother also had a BCG scar. METHODS In a randomized controlled trial (RCT) of early MV in children aged 4.5 months, the BCG-scar status of the children and their mother were registered at enrollment at 4.5 months of age. The children were followed up until they were 36 months of age. Using a Cox proportional hazards model, we compared mortality rate ratios according to maternal and child BCG-scar status after adjusting for where the BCG vaccine was given (the national hospital or elsewhere). We censored for other interventions that have immunomodulating effects on child survival, including neonatal vitamin A supplementation and early MV. RESULTS A total of 2213 children had not received neonatal vitamin A supplementation and early MV; 83% of these children and 44% of the mothers had a BCG scar. Children whose mother had a BCG scar were not more likely to have a BCG scar than those whose mother did not have a BCG scar (risk ratio, 1.01 [95% confidence interval (CI), 0.98-1.05]). Among the children, having a BCG scar was associated with a 41% (95% CI, 5%-64%) lower mortality between the ages of 4.5 and 36 months. The reduction in mortality was 66% (95% CI, 33%-83%) if the mother also had a BCG scar but only 8% (95% CI, -83% to 53%) if the mother had no BCG scar (test of interaction, P = .04). CONCLUSIONS Maternal BCG priming might be important for the effect of BCG vaccination on child survival. Ensuring better BCG vaccine scarring among mothers and children could have a considerable effect on child mortality levels.
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Affiliation(s)
| | - Christian Bjerregård Øland
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Artillerivej, Copenhagen, Denmark
| | - Pauli Bles
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - Aksel Karl Georg Jensen
- Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Artillerivej, Copenhagen, Denmark.,Section of Biostatistics, University of Copenhagen, Denmark
| | - Poul-Erik Kofoed
- Department of Paediatrics, Kolding Hospital, Sygehusvej, Kolding, Denmark
| | - Hilton Whittle
- London School of Hygiene and Tropical Medicine, United Kingdom
| | - L Charlotte J de Bree
- Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Artillerivej, Copenhagen, Denmark.,Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cesario Martins
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - Christine S Benn
- Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Artillerivej, Copenhagen, Denmark.,OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital
| | - Peter Aaby
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Artillerivej, Copenhagen, Denmark
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19
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Steiniche MM, Thysen SM, Jensen AKG, Rodrigues A, Martins C, Meyrowitsch DW, Aaby P, Fisker AB. The effect of early measles vaccination on morbidity and growth: A randomised trial from Guinea-Bissau. Vaccine 2020; 38:2487-2494. [PMID: 32061387 DOI: 10.1016/j.vaccine.2020.01.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/25/2020] [Accepted: 01/31/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Measles vaccine (MV) has beneficial non-specific effects protecting against non-measles infections in some situations. Within a trial of the effect of MV on mortality, we assessed effects of early MV on the secondary outcomes consultations and growth, overall, and by sex and exposure to campaigns with oral polio vaccine (OPV). MATERIALS AND METHODS Children were randomly assigned to MV at 4.5 + 9 months or MV at 9 months as recommended. At enrolment and 9 months children had their mid-upper-arm-circumference (MUAC) and weight measured. Consultations (out/inpatient) were registered at monthly home visits. Weight-for-age and MUAC-for-age Z-scores were obtained using the WHO growth reference and compared by group in linear regression models. Consultation rates between enrolment and 9 months were compared in Cox proportional hazards models, providing consultation Hazard Ratios (HRs) for early MV versus no early MV. We tested whether the effect of early MV was modified by OPV campaigns by splitting observation time at exposure to OPV campaigns. RESULTS Among 3548 children enrolled between 2012 and 2015, early MV had no effect on MUAC-for-age (mean difference comparing early MV vs. no MV -0.01, 95% CI -0.06-0.04), weight-for-age (mean difference -0.03, 95% CI -0.07-0.02) or rates of consultations (HR = 1.03, 95% CI 0.92-1.16). The rate of consultations for children enrolled was lower after exposure to OPV campaigns (HR = 0.81, 95% CI 0.71-0.92). The effect of MV differed before exposure to OPV campaigns (HR = 1.12, 95% CI 0.98-1.29) and after OPV campaigns (HR = 0.83, 95% CI 0.67-1.03) (test for interaction: p = 0.03). Associations did not differ by sex. CONCLUSION Early MV had no overall effect on consultation rates and growth between enrolment and 9 months of age. However, early MV tended to have beneficial effects for children subsequently exposed to OPV campaigns. As beneficial effects were observed in subgroups, the results should be interpreted with caution. CLINICAL TRIALS REGISTRATION NCT01644721.
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Affiliation(s)
- Mette Møller Steiniche
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen S, Denmark
| | - Sanne Marie Thysen
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen S, Denmark; Center for Global Health (GloHAU), Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - Aksel Karl Georg Jensen
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen S, Denmark; Section of Biostatistics, University of Copenhagen, Copenhagen K, Denmark
| | | | - Cesario Martins
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen K, Denmark
| | - Peter Aaby
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Ane Bærent Fisker
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen S, Denmark; OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense C, Denmark.
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20
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Varma A, Jensen AKG, Thysen SM, Pedersen LM, Aaby P, Fisker AB. Research protocol of two concurrent cluster-randomized trials: Real-life Effect of a CAMPaign with Measles Vaccination (RECAMP-MV) and Real-life Effect of a CAMPaign with Oral Polio Vaccination (RECAMP-OPV) on mortality and morbidity among children in rural Guinea-Bissau. BMC Public Health 2019; 19:1506. [PMID: 31711464 PMCID: PMC6849174 DOI: 10.1186/s12889-019-7813-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 10/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Measles and oral polio vaccinations may reduce child mortality to an extent that cannot be explained by prevention of measles and polio infections; these vaccines seem to have beneficial non-specific effects. In the last decades, billions of children worldwide have received measles vaccine (MV) and oral polio vaccine (OPV) through campaigns. Meanwhile the under-five child mortality has declined. Past MV and OPV campaigns may have contributed to this decline, even in the absence of measles and polio infections. However, cessation of these campaigns, once their targeted infections are eradicated, may reverse the decline in the under-five child mortality. No randomized trial has assessed the real-life effect of either campaign on child mortality and morbidity. We present the research protocol of two concurrent trials: RECAMP-MV and RECAMP-OPV. METHODS Both trials are cluster-randomized trials among children registered in Bandim Health Project's rural health and demographic surveillance system throughout Guinea-Bissau. RECAMP-MV is conducted among children aged 9-59 months and RECAMP-OPV is conducted among children aged 0-8 months. We randomized 222 geographical clusters to intervention or control clusters. In intervention clusters, children are offered MV or OPV (according to age at enrolment) and a health check-up. In control clusters, children are offered only a health check-up. Enrolments began in November 2016 (RECAMP-MV) and March 2017 (RECAMP-OPV). We plan 18,000 enrolments for RECAMP-MV with an average follow-up period of 18 months and 10,000 enrolments for RECAMP-OPV with an average follow-up period of 10 months. Data collection is ongoing. The primary outcome in both trials is non-accidental death or non-accidental first non-fatal hospitalization with overnight stay (composite outcome). Secondary outcomes are: non-accidental death, repeated non-fatal hospitalizations with overnight stay, cause-specific primary outcome, outpatient visit, and illness. We obtained ethical approval from Guinea-Bissau and consultative approval from Denmark. DISCUSSION Cluster randomization and minimum risk of loss to follow-up are strengths, and no placebo a limitation. Our trials challenge the understanding that MV and OPV only prevent measles and polio, and that once both infections are eradicated, campaigns with MV and OPV can be phased out without negative implications on child health and survival. TRIAL REGISTRATION NCT03460002.
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Affiliation(s)
- A Varma
- Department of Clinical Research, OPEN, University of Southern Denmark, Winsløwparken 19, 5000, Odense C, Denmark. .,Bandim Health Project, Indepth Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau. .,Research Center of Vitamins and Vaccines, Statens Serum Institut, Bandim Health Project, Artillerivej 5, 2300, Copenhagen, Denmark.
| | - A K G Jensen
- Department of Clinical Research, OPEN, University of Southern Denmark, Winsløwparken 19, 5000, Odense C, Denmark.,Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen K, Denmark
| | - S M Thysen
- Department of Clinical Research, OPEN, University of Southern Denmark, Winsløwparken 19, 5000, Odense C, Denmark.,Bandim Health Project, Indepth Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau.,Department of Public Health, University of Aarhus, Bartholins Alle 2, 8000, Aarhus C, Denmark
| | - L M Pedersen
- Department of Clinical Research, OPEN, University of Southern Denmark, Winsløwparken 19, 5000, Odense C, Denmark.,Bandim Health Project, Indepth Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau
| | - P Aaby
- Department of Clinical Research, OPEN, University of Southern Denmark, Winsløwparken 19, 5000, Odense C, Denmark.,Bandim Health Project, Indepth Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau.,Research Center of Vitamins and Vaccines, Statens Serum Institut, Bandim Health Project, Artillerivej 5, 2300, Copenhagen, Denmark
| | - A B Fisker
- Department of Clinical Research, OPEN, University of Southern Denmark, Winsløwparken 19, 5000, Odense C, Denmark. .,Bandim Health Project, Indepth Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau. .,Research Center of Vitamins and Vaccines, Statens Serum Institut, Bandim Health Project, Artillerivej 5, 2300, Copenhagen, Denmark.
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21
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Mathisen J, Jensen AKG, Andersen I, Andersen GS, Hvidtfeldt UA, Rod NH. Education and T2DM: the role of differential exposure and susceptibility to overweight and obesity. Eur J Public Health 2019. [DOI: 10.1093/eurpub/ckz187.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
There is a clear educational gradient in type 2 diabetes and differential exposure and susceptibility to overweight and obesity across educational groups may explain part of this gradient. Previous studies have mainly addressed differential exposure to overweight/obesity, even though the pathways are highly intertwined. We take advantage of novel methodological developments to assess the simultaneous contribution of both pathways. We further compare these analyses to more traditional approaches.
Methods
A prospective cohort of 53,159 Danish men and women, aged 50-64 years at enrollment in 1993-1997, were followed for a mean of 14.7 years. We used national register data to ascertain education and incident type 2 diabetes. Overweight/obesity was determined by BMI. Using a marginal structural approach and a three-way effect decomposition, we estimated rate differences of type 2 diabetes by education and decomposed these into direct, indirect and mediated interactive proportions. We compared this approach to traditional and separate approaches to mediation and interaction analysis.
Results
Compared with high education, medium education was associated with 316 (95% CI: 268-363) extra cases of type 2 diabetes per 100,000 person-years, and low education with 454 (95% CI: 398-510) extra cases. Differential exposure to overweight/obesity accounted for 29% (95% CI: 24-36) and 37% (95% CI: 31-45) of the cases in the medium and low educational levels, respectively, while differential susceptibility accounted for 6% (95% CI: 3-10) and 9% (95%CI 4-14). Traditional approaches suggested stronger effects of both pathways.
Conclusions
Differential exposure and susceptibility to overweight/obesity are both important pathways in the education-type 2 diabetes association, and the results emphasize the importance of addressing them simultaneously.
Key messages
Lower educated groups are more exposed and susceptible to the adverse effects of overweight/obesity with regard to type 2 diabetes, suggesting a large preventive potential. Future studies could benefit from estimating both differential exposure and differential susceptibility to better understand social inequality in type 2 diabetes and other health outcomes.
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Affiliation(s)
- J Mathisen
- Section of Social Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A K G Jensen
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, USA
| | - I Andersen
- Section of Social Medicine, University of Copenhagen, Copenhagen, Denmark
| | - G S Andersen
- Steno Diabetes Center, Capital Region, Copenhagen, Denmark
| | - U A Hvidtfeldt
- Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark
| | - N H Rod
- Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
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22
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Granholm A, Perner A, Krag M, Marker S, Hjortrup PB, Haase N, Holst LB, Collet MO, Jensen AKG, Møller MH. External validation of the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU). Acta Anaesthesiol Scand 2019; 63:1216-1224. [PMID: 31273763 DOI: 10.1111/aas.13422] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/26/2019] [Accepted: 05/16/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Simplified Mortality Score for the Intensive Care Unit (SMS-ICU) is a clinical prediction model, which estimates the risk of 90-day mortality in acutely ill adult ICU patients using 7 readily available variables. We aimed to externally validate the SMS-ICU and compare its discrimination with existing prediction models used with 90-day mortality as the outcome. METHODS We externally validated the SMS-ICU using data from 3282 patients included in the Stress Ulcer Prophylaxis in the Intensive Care Unit trial, which randomised acutely ill adult ICU patients with risk factors for gastrointestinal bleeding to prophylactic pantoprazole or placebo in 33 ICUs in Europe. We assessed discrimination, calibration and overall performance of the SMS-ICU and compared discrimination with the commonly used and more complex SAPS II and SOFA scores. RESULTS Mortality at day 90 was 30.7%. The discrimination (area under the receiver operating characteristic curve) for the SMS-ICU was 0.67 (95% CI: 0.65-0.69), as compared with 0.68 (95% CI: 0.66-0.70, P = 0.35) for SAPS II and 0.63 (95% CI: 0.61-0.65, P < 0.001) for the SOFA score. Calibration (intercept and slope) was 0.001 and 0.786, respectively, and Nagelkerke's R2 (overall performance) was 0.06. The proportions of missing data for the SMS-ICU, SAPS II and SOFA scores were 0.2%, 8.5% and 6.8%, respectively. CONCLUSIONS Discrimination for 90-day mortality of the SMS-ICU in this cohort was poor, but similar to SAPS II and better than that of the SOFA score with markedly less missing data.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Mette Krag
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Søren Marker
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Peter Buhl Hjortrup
- Centre for Research in Intensive Care Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Zealand University Hospital Køge Denmark
| | - Nicolai Haase
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Lars Broksø Holst
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Marie Oxenbøll Collet
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Aksel Karl Georg Jensen
- Centre for Research in Intensive Care Copenhagen Denmark
- Section of Biostatistics University of Copenhagen Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
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Thysen SM, Jensen AKG, Rodrigues A, Borges IDS, Aaby P, Benn C, Fisker A. Can earlier BCG vaccination reduce early infant mortality? Study protocol for a cluster randomised trial in Guinea-Bissau. BMJ Open 2019; 9:e025724. [PMID: 31551370 PMCID: PMC6773322 DOI: 10.1136/bmjopen-2018-025724] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION The BCG vaccine is designed to protect against tuberculosis, but the vaccine may have broader effects. In 2014, the Strategic Advisory Group of Experts on Immunization reviewed the literature on non-specific effects of BCG, and concluded that the evidence was consistent with beneficial non-specific effects and requested further randomised trials. METHODS AND ANALYSES Within the Bandim Health Project's urban and rural health and demographic surveillance systems, we will conduct a cluster-randomised trial in six suburban districts and 55 rural villages. Infants are enrolled at a home visit before 72 hours of life. In intervention clusters, children are vaccinated with BCG and oral polio vaccine (OPV). In control clusters, the caregivers are informed about vaccination opportunities. Using Cox-proportional hazards models, we will test whether BCG and OPV provided at a single home visit can reduce early infant mortality up to 60 days.The trial was initiated with a pilot study in Biombo region in June 2015. The trial was scaled up to full study including Oio and Cacheu regions in July 2016. The trial was expanded to include the urban study area in July 2017. ETHICS AND DISSEMINATION BCG vaccination is delayed in many low-income settings. WHO-recommended home visits are resource demanding and vaccines are not part of the recommendation. Utilising the home visits to provide BCG and OPV may provide countries with a further incentive to introduce a single home visit. In countries, where home visits are already in place, vaccines can easily be added to reduce early infant mortality. The trial is approved by the Guinean Ethical Committee (Reference number: 0016/CNES/INASA/2015) and the Danish Ethics Committee has given its consultative approval. The results of the trial will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02504203; Pre-results.
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Affiliation(s)
- Sanne M Thysen
- OPEN, University of Southern Denmark, Odense, Denmark
- Research Center of Vitamins and Vaccines, Statens Serum Institut, Copenhagen S, Denmark
- Bandim Health Project, Bandim Health Project, Bissau, Guinea-Bissau
| | | | | | | | - Peter Aaby
- Research Center of Vitamins and Vaccines, Statens Serum Institut, Copenhagen S, Denmark
- Bandim Health Project, Bandim Health Project, Bissau, Guinea-Bissau
| | - Christine Benn
- OPEN, University of Southern Denmark, Odense, Denmark
- Research Center of Vitamins and Vaccines, Statens Serum Institut, Copenhagen S, Denmark
- Bandim Health Project, Bandim Health Project, Bissau, Guinea-Bissau
| | - Ane Fisker
- OPEN, University of Southern Denmark, Odense, Denmark
- Research Center of Vitamins and Vaccines, Statens Serum Institut, Copenhagen S, Denmark
- Bandim Health Project, Bandim Health Project, Bissau, Guinea-Bissau
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Granholm A, Perner A, Jensen AKG, Møller MH. Important methodological flaws in the recently published clinical prediction model the REMEMBER score. Crit Care 2019; 23:71. [PMID: 30845996 PMCID: PMC6407253 DOI: 10.1186/s13054-019-2363-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 02/17/2019] [Indexed: 08/29/2023]
Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Inge Lehmanns Vej 5, 2100, Copenhagen, Denmark.
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Inge Lehmanns Vej 5, 2100, Copenhagen, Denmark.,Centre for Research in Intensive Care, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Centre for Research in Intensive Care, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Inge Lehmanns Vej 5, 2100, Copenhagen, Denmark.,Centre for Research in Intensive Care, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Benn CS, Fisker AB, Rieckmann A, Jensen AKG, Aaby P. How to evaluate potential non-specific effects of vaccines: the quest for randomized trials or time for triangulation? Expert Rev Vaccines 2018; 17:411-420. [PMID: 29715057 DOI: 10.1080/14760584.2018.1471987] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Emerging evidence suggests that vaccines, in addition to their disease-specific effects, have important non-specific effects (NSEs), which contribute to their overall effect on mortality and morbidity. Immunological studies have shown that NSEs are biologically plausible. Many advocate that randomized controlled trials (RCTs) with overall mortality or morbidity as the outcome are the only way forward to confirm or refute NSEs. AREAS COVERED We discuss the limitations of using RCTs only as a tool to evaluate NSEs of vaccines. Such RCTs can be ethically problematic, they are time consuming and expensive. Furthermore, they only assess the NSEs in a given context, but it is inherent in the concept of NSEs that the NSEs of a given vaccine are modified by other immunomodulatory conditions. As an alternative, we propose that triangulation of RCTs and observational studies, merging multiple lines of evidence with different underlying bias structures, can build a strong argument for causality. We examine two examples related to measles vaccine and oral polio vaccine. EXPERT COMMENTARY Using RCTs alone to evaluate NSEs of vaccines severely limits the possibilities for studying NSEs. Results from both RCTs and non-RCT studies should be triangulated to strengthen causal interpretation.
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Affiliation(s)
- Christine Stabell Benn
- a Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project , Statens Serum Institut , Copenhagen S , Denmark.,b OPEN, Institute of Clinical Research, and DIAS , University of Southern Denmark/Odense University Hospital , Odense , Denmark
| | - Ane Bærent Fisker
- a Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project , Statens Serum Institut , Copenhagen S , Denmark.,b OPEN, Institute of Clinical Research, and DIAS , University of Southern Denmark/Odense University Hospital , Odense , Denmark.,c Bandim Health Project , Indepth Network , Bissau , Guinea-Bissau
| | - Andreas Rieckmann
- a Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project , Statens Serum Institut , Copenhagen S , Denmark
| | - Aksel Karl Georg Jensen
- a Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project , Statens Serum Institut , Copenhagen S , Denmark.,d Section of Biostatistics , University of Copenhagen , Copenhagen , Denmark
| | - Peter Aaby
- a Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project , Statens Serum Institut , Copenhagen S , Denmark.,c Bandim Health Project , Indepth Network , Bissau , Guinea-Bissau
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Granholm A, Perner A, Jensen AKG, Møller MH. Trustworthy or flawed clinical prediction rule? Crit Care 2018; 22:31. [PMID: 29415758 PMCID: PMC5804002 DOI: 10.1186/s13054-018-1961-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 01/18/2018] [Indexed: 11/23/2022] Open
Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Centre for Research in Intensive Care, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Centre for Research in Intensive Care, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Centre for Research in Intensive Care, Blegdamsvej 9, 2100 Copenhagen, Denmark
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27
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Maaløe N, Housseine N, Meguid T, Nielsen BB, Jensen AKG, Khamis RS, Mohamed AG, Ali MM, Said SM, van Roosmalen J, Bygbjerg IC. Authors' reply re: Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of Zanzibar: A quasi-experimental pre-post-study (The PartoMa study). BJOG 2017; 125:394-395. [PMID: 29266853 DOI: 10.1111/1471-0528.14962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Natasha Housseine
- Mnazi Mmoja Hospital, Zanzibar, Tanzania.,Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Tarek Meguid
- Mnazi Mmoja Hospital, Zanzibar, Tanzania.,School of Health & Medical Sciences, State University of Zanzibar, Zanzibar, Tanzania
| | - Birgitte Bruun Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | | | - Jos van Roosmalen
- Athena Institute, VU University of Amsterdam, Amsterdam, the Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Thøstesen LM, Kjaer HF, Pihl GT, Nissen TN, Birk NM, Kjaergaard J, Jensen AKG, Aaby P, Olesen AW, Stensballe LG, Jeppesen DL, Benn CS, Kofoed PE. Neonatal BCG has no effect on allergic sensitization and suspected food allergy until 13 months. Pediatr Allergy Immunol 2017; 28:588-596. [PMID: 28660649 DOI: 10.1111/pai.12748] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Vaccination with Bacillus Calmette-Guérin (BCG) is used in many countries as protection against tuberculosis. Studies have suggested that BCG may also have non-specific effects, reducing non-tuberculosis mortality, morbidity, and atopic manifestations. In this study, we evaluated the effect of neonatal BCG vaccination on allergic sensitization and suspected food allergy at 13 months of age. METHODS The Danish Calmette Study was conducted from 2012 to 2015 at three Danish hospitals. Within 7 days of birth, the 4262 newborns of 4184 included mothers were randomized 1:1 to BCG or to a no-intervention control group. Exclusion criteria were gestational age <32 weeks, birth weight <1000 g, known immunodeficiency, or no Danish-speaking parent. Follow-up information was collected through telephone interviews at 3 and 13 months of age. Subgroups of participants were offered blood sampling at 13 months of age. RESULTS By 13 months of age, the parents and/or general practitioners of 5.6% (117/2089) of the children in the BCG group and 6.1% (126/2061) of the control group suspected food allergy, resulting in a risk ratio comparing BCG-vaccinated children with control children of 0.91 (95% CI 0.71-1.16). Among 1370 blood samples, sensitization (Phadiatop Infant >0.35 kUA/L) was found in 55 of 743 (7.4%) children in the BCG group and 50 of 627 (8.0%) of the control group (risk ratio 0.94 [0.65-1.36]). CONCLUSION In this randomized clinical trial, neonatal BCG had no significant effect on suspected food allergy or on sensitization at 13 months of age.
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Affiliation(s)
- Lisbeth Marianne Thøstesen
- Department of Pediatrics, Kolding Hospital, Kolding, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Fomsgaard Kjaer
- Allergy Centre and Department of Dermatology, Odense University Hospital, Odense C, Denmark
| | - Gitte Thybo Pihl
- Department of Pediatrics, Kolding Hospital, Kolding, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Nina Marie Birk
- Department of Pediatrics, 460, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jesper Kjaergaard
- Research Unit Women's and Childrens' Health, The Department of Pediatrics and Adolescent Medicine, Juliane Marie Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen Ø, Denmark
| | - Aksel Karl Georg Jensen
- Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen S, Denmark.,Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Peter Aaby
- Bandim Health Project, Statens Serum Institut, Copenhagen S, Denmark
| | - Annette Wind Olesen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense C, Denmark
| | - Lone Graff Stensballe
- The Department of Pediatrics and Adolescent Medicine, Juliane Marie Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen Ø, Denmark
| | | | - Christine Stabell Benn
- Research Centre for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen S, Denmark.,OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - Poul-Erik Kofoed
- Department of Pediatrics, Kolding Hospital, Kolding, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
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29
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Hansen NS, Byberg S, Hervig Jacobsen L, Bjerregaard-Andersen M, Jensen AKG, Martins C, Aaby P, Skov Jensen J, Stabell Benn C, Whittle H. Effect of early measles vaccine on pneumococcal colonization: A randomized trial from Guinea-Bissau. PLoS One 2017; 12:e0177547. [PMID: 28545041 PMCID: PMC5435222 DOI: 10.1371/journal.pone.0177547] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/27/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Measles vaccine (MV) may have non-specific beneficial effects for child health and particularly seems to prevent respiratory infections. Streptococcus pneumoniae is the leading cause of bacterial pneumonia among children worldwide, and nasopharyngeal colonization precedes infection. OBJECTIVE We investigated whether providing early MV at 18 weeks of age reduced pneumococcal colonization and/or density up to 9 months of age. METHOD The study was conducted in 2013-2014 in Guinea-Bissau. Pneumococcal vaccine was not part of the vaccination program. Infants aged 18 weeks were block-randomized 2:1 to early or no early MV; at age 9 months, all children were offered MV as per current policy. Nasopharyngeal swabs were taken at baseline, age 6.5 months, and age 9 months. Pneumococcal density was determined by q-PCR. Prevalence ratios of pneumococcal colonization and recent antibiotic treatment (yes/no) by age 6.5 months (PR6.5) and age 9 months (PR9) were estimated using Poisson regression with robust variance estimates while the pneumococcal geometric mean ratio (GMR6.5 and GMR9) was obtained using OLS regression. RESULTS Analyses included 512 children; 346 early MV-children and 166 controls. At enrolment, the pneumococcal colonization prevalence was 80% (411/512). Comparing early MV-children with controls, the PR6.5 was 1.02 (95%CI = 0.94-1.10), and the PR9 was 1.04 (0.96-1.12). The GMR6.5 was 1.02 (0.55-1.89), and the GMR9 was 0.69 (0.39-1.21). Early MV-children tended to be less frequently treated with antibiotics prior to follow up (PR6.5 0.60 (0.34-1.05) and PR9 0.87 (0.50-1.53)). Antibiotic treatment was associated with considerably lower colonization rates, PR6.5 0.85 (0.71-1.01) and PR9 0.66 (0.52-0.84), as well as lower pneumococcal density, GMR6.5 0.32 (0.12-0.86) and GMR9 0.52 (0.18-1.52). CONCLUSION Early MV at age 18 weeks had no measurable effect on pneumococcal colonization prevalence or density. Higher consumption of antibiotics among controls may have blurred an effect of early MV. TRIAL REGISTRATION clinicaltrials.gov NCT01486355.
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Affiliation(s)
- Nadja Skadkær Hansen
- Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Stine Byberg
- Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Lars Hervig Jacobsen
- Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Morten Bjerregaard-Andersen
- Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Aksel Karl Georg Jensen
- Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Cesario Martins
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Peter Aaby
- Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Jørgen Skov Jensen
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Christine Stabell Benn
- Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Odense Patient data Explorative Network, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Hilton Whittle
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
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Thøstesen LM, Stensballe LG, Pihl GT, Kjærgaard J, Birk NM, Nissen TN, Jensen AKG, Aaby P, Olesen AW, Jeppesen DL, Benn CS, Kofoed PE. Neonatal BCG vaccination has no effect on recurrent wheeze in the first year of life: A randomized clinical trial. J Allergy Clin Immunol 2017; 140:1616-1621.e3. [PMID: 28347733 DOI: 10.1016/j.jaci.2016.12.990] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 11/22/2016] [Accepted: 12/23/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Recurrent wheeze (RW) is frequent in childhood. Studies have suggested that BCG vaccination can have nonspecific effects, reducing general nontuberculosis morbidity, including respiratory tract infections and atopic diseases. The mechanisms behind these nonspecific effects of BCG are not fully understood, but a shift from a TH2 to a TH1 response has been suggested as a possible explanation. OBJECTIVE We hypothesized that BCG at birth would reduce the cumulative incidence of RW during the first year of life. METHODS The Danish Calmette Study is a multicenter randomized trial conducted from 2012-2015 at 3 Danish hospitals. The 4262 newborns of 4184 included mothers were randomized 1:1 to BCG (SSI strain 1331) or to a no-intervention control group within 7 days of birth; siblings were randomized together as one randomization unit. Exclusion criteria were gestational age of less than 32 weeks, birth weight of less than 1000 g, known immunodeficiency, or no Danish-speaking parent. Information was collected through telephone interviews and clinical examinations at 3 and 13 months of age; data collectors were blind to randomization group. RW was defined in several ways, with the main definition being physician-diagnosed and medically treated RW up to 13 months of age. RESULTS By 13 months, 211 (10.0%) of 2100 children in the BCG group and 195 (9.4%) of 2071 children in the control group had received a diagnosis of RW from a medical doctor and received antiasthma treatment (relative risk, 1.07; 95% CI, 0.89-1.28). Supplementary analyses were made, including an analysis of baseline risk factors for development of RW. CONCLUSION Neonatal BCG had no effect on the development of RW before 13 months of age.
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Affiliation(s)
- Lisbeth Marianne Thøstesen
- Department of Pediatrics, Kolding Hospital, and the Institute of Regional Health Research, University of Southern Denmark, Kolding, Denmark.
| | - Lone Graff Stensballe
- Department of Paediatrics and Adolescent Medicine, Juliane Marie Centret, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gitte Thybo Pihl
- Department of Pediatrics, Kolding Hospital, and the Institute of Regional Health Research, University of Southern Denmark, Kolding, Denmark
| | - Jesper Kjærgaard
- Research Unit for Women's and Childrens' Health, Department of Paediatrics and Adolescent Medicine, Juliane Marie Centret, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nina Marie Birk
- Department of Pediatrics, Copenhagen University Hospital, Hvidovre, Denmark
| | | | - Aksel Karl Georg Jensen
- Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, and the Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Peter Aaby
- Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Annette Wind Olesen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | | | - Christine Stabell Benn
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, and OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - Poul-Erik Kofoed
- Department of Pediatrics, Kolding Hospital, and the Institute of Regional Health Research, University of Southern Denmark, Kolding, Denmark
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Granholm A, Perner A, Krag M, Hjortrup PB, Haase N, Holst LB, Marker S, Collet MO, Jensen AKG, Møller MH. Simplified Mortality Score for the Intensive Care Unit (SMS-ICU): protocol for the development and validation of a bedside clinical prediction rule. BMJ Open 2017; 7:e015339. [PMID: 28279999 PMCID: PMC5353313 DOI: 10.1136/bmjopen-2016-015339] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Mortality prediction scores are widely used in intensive care units (ICUs) and in research, but their predictive value deteriorates as scores age. Existing mortality prediction scores are imprecise and complex, which increases the risk of missing data and decreases the applicability bedside in daily clinical practice. We propose the development and validation of a new, simple and updated clinical prediction rule: the Simplified Mortality Score for use in the Intensive Care Unit (SMS-ICU). METHODS AND ANALYSIS During the first phase of the study, we will develop and internally validate a clinical prediction rule that predicts 90-day mortality on ICU admission. The development sample will comprise 4247 adult critically ill patients acutely admitted to the ICU, enrolled in 5 contemporary high-quality ICU studies/trials. The score will be developed using binary logistic regression analysis with backward stepwise elimination of candidate variables, and subsequently be converted into a point-based clinical prediction rule. The general performance, discrimination and calibration of the score will be evaluated, and the score will be internally validated using bootstrapping. During the second phase of the study, the score will be externally validated in a fully independent sample consisting of 3350 patients included in the ongoing Stress Ulcer Prophylaxis in the Intensive Care Unit trial. We will compare the performance of the SMS-ICU to that of existing scores. ETHICS AND DISSEMINATION We will use data from patients enrolled in studies/trials already approved by the relevant ethical committees and this study requires no further permissions. The results will be reported in accordance with the Transparent Reporting of multivariate prediction models for Individual Prognosis Or Diagnosis (TRIPOD) statement, and submitted to a peer-reviewed journal.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care, Copenhagen, Denmark
| | - Mette Krag
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Peter Buhl Hjortrup
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Nicolai Haase
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Lars Broksø Holst
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Søren Marker
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Marie Oxenbøll Collet
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | | | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
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