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Chandna A, Keang S, Vorlark M, Sambou B, Chhingsrean C, Sina H, Vichet P, Patel K, Habsreng E, Riedel A, Mwandigha L, Koshiaris C, Perera-Salazar R, Turner P, Chanpheaktra N, Turner C. A Prognostic Model for Critically Ill Children in Locations With Emerging Critical Care Capacity. Pediatr Crit Care Med 2024; 25:189-200. [PMID: 37947482 PMCID: PMC10904005 DOI: 10.1097/pcc.0000000000003394] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVES To develop a clinical prediction model to risk stratify children admitted to PICUs in locations with limited resources, and compare performance of the model to nine existing pediatric severity scores. DESIGN Retrospective, single-center, cohort study. SETTING PICU of a pediatric hospital in Siem Reap, northern Cambodia. PATIENTS Children between 28 days and 16 years old admitted nonelectively to the PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical and laboratory data recorded at the time of PICU admission were collected. The primary outcome was death during PICU admission. One thousand five hundred fifty consecutive nonelective PICU admissions were included, of which 97 died (6.3%). Most existing severity scores achieved comparable discrimination (area under the receiver operating characteristic curves [AUCs], 0.71-0.76) but only three scores demonstrated moderate diagnostic utility for triaging admissions into high- and low-risk groups (positive likelihood ratios [PLRs], 2.65-2.97 and negative likelihood ratios [NLRs], 0.40-0.46). The newly derived model outperformed all existing severity scores (AUC, 0.84; 95% CI, 0.80-0.88; p < 0.001). Using one particular threshold, the model classified 13.0% of admissions as high risk, among which probability of mortality was almost ten-fold greater than admissions triaged as low-risk (PLR, 5.75; 95% CI, 4.57-7.23 and NLR, 0.47; 95% CI, 0.37-0.59). Decision curve analyses indicated that the model would be superior to all existing severity scores and could provide utility across the range of clinically plausible decision thresholds. CONCLUSIONS Existing pediatric severity scores have limited potential as risk stratification tools in resource-constrained PICUs. If validated, our prediction model would be a readily implementable mechanism to support triage of critically ill children at admission to PICU and could provide value across a variety of contexts where resource prioritization is important.
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Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
| | - Suy Keang
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Department of Intensive Care Medicine, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Meas Vorlark
- Department of Intensive Care Medicine, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Bran Sambou
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Chhay Chhingsrean
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Heav Sina
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Pav Vichet
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Kaajal Patel
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Department of Global Child Health, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Eang Habsreng
- Department of Intensive Care Medicine, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Arthur Riedel
- Department of Global Child Health, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Lazaro Mwandigha
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Constantinos Koshiaris
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rafael Perera-Salazar
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Claudia Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Angkor Hospital for Children, Siem Reap, Cambodia
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Agarwal G, Moore S, Sadler R, Varghese S, Turner A, Chen LY, Larham J, Gray N, Carty O, Barrett J, Koshiaris C, Kothari J, Bowcock S, Oppermann U, Gamble V, Cook G, Kyriakou C, Drayson M, Basu S, McDonald S, McKinley S, Gooding S, Javaid MK, Ramasamy K. Longitudinal dynamics and clinically available predictors of poor response to COVID-19 vaccination in multiple myeloma. Haematologica 2024. [PMID: 38268439 DOI: 10.3324/haematol.2023.284286] [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] [Received: 09/17/2023] [Indexed: 01/26/2024] Open
Abstract
Not available.
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Affiliation(s)
- Gaurav Agarwal
- Division of Haematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Ross Sadler
- Oxford University Hospitals NHS Trust, Oxford
| | | | - Alison Turner
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford
| | | | | | - Nathanael Gray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford
| | | | - Joe Barrett
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford
| | | | | | | | - Udo Oppermann
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford
| | - Vicky Gamble
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford
| | - Gordon Cook
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | | | | | - Supratik Basu
- The Royal Wolverhampton NHS Trust, Wolverhampton, UK; University of Wolverhampton, Wolverhampton
| | | | | | - Sarah Gooding
- Oxford University Hospitals NHS Trust, Oxford, UK; MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford
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Chandna A, Mwandigha L, Koshiaris C, Limmathurotsakul D, Nosten F, Lubell Y, Perera-Salazar R, Turner C, Turner P. External validation of clinical severity scores to guide referral of paediatric acute respiratory infections in resource-limited primary care settings. Sci Rep 2023; 13:19026. [PMID: 37923813 PMCID: PMC10624658 DOI: 10.1038/s41598-023-45746-4] [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: 03/29/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
Accurate and reliable guidelines for referral of children from resource-limited primary care settings are lacking. We identified three practicable paediatric severity scores (the Liverpool quick Sequential Organ Failure Assessment (LqSOFA), the quick Pediatric Logistic Organ Dysfunction-2, and the modified Systemic Inflammatory Response Syndrome) and externally validated their performance in young children presenting with acute respiratory infections (ARIs) to a primary care clinic located within a refugee camp on the Thailand-Myanmar border. This secondary analysis of data from a longitudinal birth cohort study consisted of 3010 ARI presentations in children aged ≤ 24 months. The primary outcome was receipt of supplemental oxygen. We externally validated the discrimination, calibration, and net-benefit of the scores, and quantified gains in performance that might be expected if they were deployed as simple clinical prediction models, and updated to include nutritional status and respiratory distress. 104/3,010 (3.5%) presentations met the primary outcome. The LqSOFA score demonstrated the best discrimination (AUC 0.84; 95% CI 0.79-0.89) and achieved a sensitivity and specificity > 0.80. Converting the scores into clinical prediction models improved performance, resulting in ~ 20% fewer unnecessary referrals and ~ 30-50% fewer children incorrectly managed in the community. The LqSOFA score is a promising triage tool for young children presenting with ARIs in resource-limited primary care settings. Where feasible, deploying the score as a simple clinical prediction model might enable more accurate and nuanced risk stratification, increasing applicability across a wider range of contexts.
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Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia.
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Lazaro Mwandigha
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Direk Limmathurotsakul
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Claudia Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Albury C, Webb H, Stokoe E, Ziebland S, Koshiaris C, Lee JJ, Aveyard P. Relationship Between Clinician Language and the Success of Behavioral Weight Loss Interventions : A Mixed-Methods Cohort Study. Ann Intern Med 2023; 176:1437-1447. [PMID: 37931269 DOI: 10.7326/m22-2360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND International guidelines recommend that primary care clinicians recognize obesity and offer treatment opportunistically, but there is little evidence on how clinicians can discuss weight and offer treatment in ways that are well received and effective. OBJECTIVE To examine relationships between language used in the clinical visit and patient weight loss. DESIGN Mixed-methods cohort study. SETTING 38 primary care clinics in England participating in the Brief Intervention for Weight Loss trial. PARTICIPANTS 246 patients with obesity seen by 87 general practitioners randomly sampled from the intervention group of the randomized clinical trial. MEASUREMENTS Conversation analysis of recorded discussions between 246 patients with obesity and 87 clinicians regarding referral to a 12-week behavioral weight management program offered as part of the randomized clinical trial. Clinicians' interactional approaches were identified and their association with patient weight loss at 12 months (primary outcome) was examined. Secondary outcomes included patients' agreement to attend weight management, attendance, loss of 5% body weight, actions taken to lose weight, and postvisit satisfaction. RESULTS Three interactional approaches were identified on the basis of clinicians' linguistic and paralinguistic practices: creating a sense of referrals as "good news" related to the opportunity of the referral (n = 62); "bad news," focusing on the harms of obesity (n = 82); or neutral (n = 102). Outcome data were missing from 57 participants, so weighted analyses were done to adjust for missingness. Relative to neutral news, good news was associated with increased agreement to attend the program (adjusted risk difference, 0.25 [95% CI, 0.15 to 0.35]), increased attendance (adjusted risk difference, 0.45 [CI, 0.34 to 0.56]), and weight change (adjusted difference, -3.60 [CI, -6.58 to -0.62]). There was no evidence of differences in mean weight change comparing bad and neutral news, and no evidence of differences in patient satisfaction across all 3 approaches. LIMITATIONS Data were audio only, so body language and nonverbal cues could not be assessed. There is potential for selection bias and residual confounding. CONCLUSION When raising the topic of excess weight in clinical visits, presenting weight loss treatment as a positive opportunity is associated with greater uptake of treatment and greater weight loss. PRIMARY FUNDING SOURCE National Institute for Health and Care Research School for Primary Care Research and the Foundation for the Sociology of Health and Illness.
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Affiliation(s)
- Charlotte Albury
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (C.A., S.Z., C.K., J.J.L., P.A.)
| | - Helena Webb
- School of Computer Science, University of Nottingham, Nottingham, United Kingdom (H.W.)
| | - Elizabeth Stokoe
- Department of Psychological and Behavioural Sciences, London School of Economics and Political Science, London, United Kingdom (E.S.)
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (C.A., S.Z., C.K., J.J.L., P.A.)
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (C.A., S.Z., C.K., J.J.L., P.A.)
| | - Joseph J Lee
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (C.A., S.Z., C.K., J.J.L., P.A.)
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (C.A., S.Z., C.K., J.J.L., P.A.)
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Henry JA, Astbury NM, Hartmann-Boyce J, Koshiaris C, Jebb SA. Use of Cognitive and Behavioral Strategies During a Weight Loss Program: A Secondary Analysis of the Doctor Referral of Overweight People to Low-Energy Total Diet Replacement Treatment (DROPLET) Trial. J Acad Nutr Diet 2023; 123:1417-1428.e17. [PMID: 37019430 PMCID: PMC10895506 DOI: 10.1016/j.jand.2023.03.016] [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: 04/06/2022] [Revised: 03/20/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Achieving a sustained energy deficit is essential for weight loss, but the cognitive and behavioral strategies that support this goal are unclear. OBJECTIVE The goal of this study was to investigate the number and type of cognitive and behavioral strategies used by participants who were enrolled in a 1-year weight loss trial and to explore associations between strategies and magnitude of weight loss at 3 months and 1 year. DESIGN The study is a secondary post-hoc exploratory analysis of data collected as part of the Doctor Referral of Overweight People to Low-Energy total diet replacement Treatment (DROPLET), a randomized controlled trial conducted in general practices in England, United Kingdom, between January 2016 and August 2017. PARTICIPANTS/SETTING This study involved 164 participants from both intervention and control groups of the DROPLET trial who completed the Oxford Food and Behaviours (OxFAB) questionnaire to assess the use of 115 strategies grouped into 21 domains used to manage their weight. INTERVENTIONS Participants were randomized to either a behavioral weight loss program involving 8 weeks total diet replacement (TDR) and 4 weeks of food reintroduction or a program delivered by a medical practice nurse over a 3-month period (usual care [UC]). MAIN OUTCOME MEASURES Weight was objectively measured at baseline, 3 months, and 1 year. Cognitive and behavioral strategies used to support weight loss were assessed using the OxFAB questionnaire at 3 months. STATISTICAL ANALYSIS PERFORMED Exploratory factor analysis was used to generate data-driven patterns of strategy use, and a linear mixed-effects model was used to examine associations between use of these patterns and weight change. RESULTS No evidence was found of a difference in the number of strategies (mean difference, 2.41; 95% confidence interval [CI], -0.83, 5.65) or the number of domains used (mean difference, -0.23; 95% CI, -0.69, 0.23) between the TDR group and the UC group. The number of strategies was not associated with weight loss at either 3 months (-0.02 kg; 95% CI, -0.11, 0.06) or 1 year (-0.05 kg; 95% CI, -0.14, 0.02). Similarly, the number of domains used was not associated with weight loss at 3 months (-0.02 kg; 95% CI, -0.53, 0.49) or 1 year (-0.07 kg; 95% CI, -0.60, 0.46). Factor analysis identified four coherent patterns of strategy use, identified as Physical Activity, Motivation, Planned Eating, and Food Purchasing patterns. Greater use of strategies in the Food Purchasing (-2.6 kg; 95% CI, -4.42, -0.71) and Planned Eating patterns (-3.20 kg; 95% CI, -4.94, -1.46) was associated with greater weight loss at 1 year. CONCLUSIONS The number of cognitive and behavioral strategies or domains used does not appear to influence weight loss, but the types of strategy appear of greater importance. Supporting people to adopt strategies linked to planned eating and food purchasing may aid long-term weight loss.
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Affiliation(s)
| | - Nerys M. Astbury
- Address correspondence to: Nerys M. Astbury, PhD, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care, Woodstock Road, Oxford OX2 6GG UK.
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Chandna A, Mahajan R, Gautam P, Mwandigha L, Dittrich S, Kumar V, Osborn J, Kumar P, Koshiaris C, Varghese GM, Lubell Y, Burza S. Point-of-care prognostication in moderate Covid-19: Analytical validation and prognostic accuracy of a soluble urokinase plasminogen activator receptor (suPAR) rapid test. PLOS Glob Public Health 2023; 3:e0001538. [PMID: 37603548 PMCID: PMC10441780 DOI: 10.1371/journal.pgph.0001538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 07/20/2023] [Indexed: 08/23/2023]
Abstract
The soluble urokinase plasminogen activator receptor (suPAR) has been proposed as a biomarker for risk stratification of patients presenting with acute infections. However, most studies evaluating suPAR have used platform-based assays, the accuracy of which may differ from point-of-care tests capable of informing timely triage in settings without established laboratory capacity. Using samples and data collected during a prospective cohort study of 425 patients presenting with moderate Covid-19 to two hospitals in India, we evaluated the analytical performance and prognostic accuracy of a commercially-available rapid diagnostic test (RDT) for suPAR, using an enzyme-linked immunosorbent assay (ELISA) as the reference standard. Our hypothesis was that the suPAR RDT might be useful for triage of patients presenting with moderate Covid-19 irrespective of its analytical performance when compared with the reference test. Although agreement between the two tests was limited (bias = -2.46 ng/mL [95% CI = -2.65 to -2.27 ng/mL]), prognostic accuracy to predict supplemental oxygen requirement was comparable, whether suPAR was used alone (area under the receiver operating characteristic curve [AUC] of RDT = 0.73 [95% CI = 0.68 to 0.79] vs. AUC of ELISA = 0.70 [95% CI = 0.63 to 0.76]; p = 0.12) or as part of a published multivariable prediction model (AUC of RDT-based model = 0.74 [95% CI = 0.66 to 0.83] vs. AUC of ELISA-based model = 0.72 [95% CI = 0.64 to 0.81]; p = 0.78). Lack of agreement between the RDT and ELISA in our cohort warrants further investigation and highlights the importance of assessing candidate point-of-care tests to ensure management algorithms reflect the assay that will ultimately be used to inform patient care. Availability of a quantitative point-of-care test for suPAR opens the door to suPAR-guided risk stratification of patients with Covid-19 and other acute infections in settings with limited laboratory capacity.
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Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Priyanka Gautam
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Lazaro Mwandigha
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sabine Dittrich
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Foundation for Innovative Diagnostics, Geneva, Switzerland
- Deggendorf Institut of Technology, European-Campus Rottal Inn, Pfarrkirchen, Germany
| | | | | | - Pragya Kumar
- Department of Community & Family Medicine, All India Institute of Medical Sciences, Patna, India
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - George M. Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Yoel Lubell
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Sakib Burza
- Médecins Sans Frontières, New Delhi, India
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Chandna A, Lubell Y, Mwandigha L, Tanunchai P, Vinitsorn A, Richard-Greenblatt M, Koshiaris C, Limmathurotsakul D, Nosten F, Abdad MY, Perera-Salazar R, Turner C, Turner P. Defining the role of host biomarkers in the diagnosis and prognosis of the severity of childhood pneumonia: a prospective cohort study. Sci Rep 2023; 13:12024. [PMID: 37491541 PMCID: PMC10368669 DOI: 10.1038/s41598-023-38731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/13/2023] [Indexed: 07/27/2023] Open
Abstract
Reliable tools to inform outpatient management of childhood pneumonia in resource-limited settings are needed. We investigated the value added by biomarkers of the host infection response to the performance of the Liverpool quick Sequential Organ Failure Assessment score (LqSOFA), for triage of children presenting with pneumonia to a primary care clinic in a refugee camp on the Thailand-Myanmar border. 900 consecutive presentations of children aged ≤ 24 months meeting WHO pneumonia criteria were included. The primary outcome was receipt of supplemental oxygen. We compared discrimination of a clinical risk score (LqSOFA) to markers of endothelial injury (Ang-1, Ang-2, sFlt-1), immune activation (CHI3L1, IP-10, IL-1ra, IL-6, IL-8, IL-10, sTNFR-1, sTREM-1), and inflammation (CRP, PCT), and quantified the net benefit of including biomarkers alongside LqSOFA. We evaluated the differential contribution of LqSOFA and host biomarkers to the diagnosis and prognosis of pneumonia severity. 49/900 (5.4%) presentations met the primary outcome. Discrimination of LqSOFA and Ang-2, the best performing biomarker, were comparable (AUC 0.82 [95% CI 0.76-0.88] and 0.81 [95% CI 0.74-0.87] respectively). Combining Ang-2 with LqSOFA improved discrimination (AUC 0.91; 95% CI 0.87-0.94; p < 0.001), and resulted in greater net benefit, with 10-30% fewer children who required oxygen supplementation incorrectly identified as safe for community-based management. Ang-2 had greater prognostic utility than LqSOFA to identify children requiring supplemental oxygen later in their illness course. Combining Ang-2 and LqSOFA could guide referrals of childhood pneumonia from resource-limited community settings. Further work on test development and integration into patient triage is required.
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Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia.
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Lazaro Mwandigha
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Phattaranit Tanunchai
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Asama Vinitsorn
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Melissa Richard-Greenblatt
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Public Health Ontario, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | | | - Direk Limmathurotsakul
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Mohammad Yazid Abdad
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Claudia Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Sheppard JP, Koshiaris C, Stevens R, Lay-Flurrie S, Banerjee A, Bellows BK, Clegg A, Hobbs FDR, Payne RA, Swain S, Usher-Smith JA, McManus RJ. The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study. PLoS Med 2023; 20:e1004223. [PMID: 37075078 PMCID: PMC10155987 DOI: 10.1371/journal.pmed.1004223] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 05/03/2023] [Accepted: 03/24/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Antihypertensives are effective at reducing the risk of cardiovascular disease, but limited data exist quantifying their association with serious adverse events, particularly in older people with frailty. This study aimed to examine this association using nationally representative electronic health record data. METHODS AND FINDINGS This was a retrospective cohort study utilising linked data from 1,256 general practices across England held within the Clinical Practice Research Datalink between 1998 and 2018. Included patients were aged 40+ years, with a systolic blood pressure reading between 130 and 179 mm Hg, and not previously prescribed antihypertensive treatment. The main exposure was defined as a first prescription of antihypertensive treatment. The primary outcome was hospitalisation or death within 10 years from falls. Secondary outcomes were hypotension, syncope, fractures, acute kidney injury, electrolyte abnormalities, and primary care attendance with gout. The association between treatment and these serious adverse events was examined by Cox regression adjusted for propensity score. This propensity score was generated from a multivariable logistic regression model with patient characteristics, medical history and medication prescriptions as covariates, and new antihypertensive treatment as the outcome. Subgroup analyses were undertaken by age and frailty. Of 3,834,056 patients followed for a median of 7.1 years, 484,187 (12.6%) were prescribed new antihypertensive treatment in the 12 months before the index date (baseline). Antihypertensives were associated with an increased risk of hospitalisation or death from falls (adjusted hazard ratio [aHR] 1.23, 95% confidence interval (CI) 1.21 to 1.26), hypotension (aHR 1.32, 95% CI 1.29 to 1.35), syncope (aHR 1.20, 95% CI 1.17 to 1.22), acute kidney injury (aHR 1.44, 95% CI 1.41 to 1.47), electrolyte abnormalities (aHR 1.45, 95% CI 1.43 to 1.48), and primary care attendance with gout (aHR 1.35, 95% CI 1.32 to 1.37). The absolute risk of serious adverse events with treatment was very low, with 6 fall events per 10,000 patients treated per year. In older patients (80 to 89 years) and those with severe frailty, this absolute risk was increased, with 61 and 84 fall events per 10,000 patients treated per year (respectively). Findings were consistent in sensitivity analyses using different approaches to address confounding and taking into account the competing risk of death. A strength of this analysis is that it provides evidence regarding the association between antihypertensive treatment and serious adverse events, in a population of patients more representative than those enrolled in previous randomised controlled trials. Although treatment effect estimates fell within the 95% CIs of those from such trials, these analyses were observational in nature and so bias from unmeasured confounding cannot be ruled out. CONCLUSIONS Antihypertensive treatment was associated with serious adverse events. Overall, the absolute risk of this harm was low, with the exception of older patients and those with moderate to severe frailty, where the risks were similar to the likelihood of benefit from treatment. In these populations, physicians may want to consider alternative approaches to management of blood pressure and refrain from prescribing new treatment.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Brandon K Bellows
- Columbia University Irving Medical Center, New York, New York, United States of America
| | - Andrew Clegg
- Academic Unit for Ageing & Stroke Research, University of Leeds, Leeds, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Health and Community Sciences, University of Exeter Medical School, Exeter, United Kingdom
| | - Subhashisa Swain
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Virdee PS, Bankhead C, Koshiaris C, Drakesmith CW, Oke J, Withrow D, Swain S, Collins K, Chammas L, Tamm A, Zhu T, Morris E, Holt T, Birks J, Perera R, Hobbs FDR, Nicholson BD. BLOod Test Trend for cancEr Detection (BLOTTED): protocol for an observational and prediction model development study using English primary care electronic health record data. Diagn Progn Res 2023; 7:1. [PMID: 36624489 PMCID: PMC9830700 DOI: 10.1186/s41512-022-00138-6] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/15/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Simple blood tests can play an important role in identifying patients for cancer investigation. The current evidence base is limited almost entirely to tests used in isolation. However, recent evidence suggests combining multiple types of blood tests and investigating trends in blood test results over time could be more useful to select patients for further cancer investigation. Such trends could increase cancer yield and reduce unnecessary referrals. We aim to explore whether trends in blood test results are more useful than symptoms or single blood test results in selecting primary care patients for cancer investigation. We aim to develop clinical prediction models that incorporate trends in blood tests to identify the risk of cancer. METHODS Primary care electronic health record data from the English Clinical Practice Research Datalink Aurum primary care database will be accessed and linked to cancer registrations and secondary care datasets. Using a cohort study design, we will describe patterns in blood testing (aim 1) and explore associations between covariates and trends in blood tests with cancer using mixed-effects, Cox, and dynamic models (aim 2). To build the predictive models for the risk of cancer, we will use dynamic risk modelling (such as multivariate joint modelling) and machine learning, incorporating simultaneous trends in multiple blood tests, together with other covariates (aim 3). Model performance will be assessed using various performance measures, including c-statistic and calibration plots. DISCUSSION These models will form decision rules to help general practitioners find patients who need a referral for further investigation of cancer. This could increase cancer yield, reduce unnecessary referrals, and give more patients the opportunity for treatment and improved outcomes.
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Affiliation(s)
- Pradeep S. Virdee
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Cynthia Wright Drakesmith
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Jason Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Diana Withrow
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Subhashisa Swain
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Kiana Collins
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Lara Chammas
- Big Data Institute, University of Oxford, Oxford, UK
| | - Andres Tamm
- Big Data Institute, University of Oxford, Oxford, UK
| | - Tingting Zhu
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Eva Morris
- Big Data Institute, University of Oxford, Oxford, UK
| | - Tim Holt
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Jacqueline Birks
- Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - F. D. Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Brian D. Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
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10
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Doogue R, Hayes P, Tucker K, Fahey T, Sheikhi A, Koshiaris C, Glynn L. Self-monitoring for improving control of blood pressure in patients with hypertension: a Cochrane intervention review. Rural Remote Health 2023; 23:8170. [PMID: 36802798 DOI: 10.22605/rrh8170] [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: 02/23/2023] Open
Abstract
BACKGROUND Hypertension is a major risk factor for cardiovascular events with only a minority of people treated to satisfactory levels. There is an increasing body of literature pertaining to the beneficial effect of self-blood pressure monitoring (SBPM) on blood pressure control in hypertensive patients. It is cost-effective, well tolerated, and has been shown to be a better predictor of end organ damage than traditional office blood pressure monitoring (OBPM). The aim of this Cochrane review is to provide an up-to-date assessment on the effectiveness of self-monitoring in the management of hypertension.Is SBPM more efficacious in reducing blood pressure, compared with OBPM or usual care?Is SBPM with additional supports more efficacious in reducing blood pressure, compared with no additional support?Are there any adverse events associated with SBPM, compared with OBPM or usual care? METHODS All randomised controlled trials of adult patients with a diagnosis of primary hypertension where the intervention of interest is SBPM will be included. Data extraction, analysis and risk of bias assessment will be carried out by two independent authors. Analysis will be based on intention-to-treat (ITT) data from individual trials. RESULTS Primary outcome measures include change in mean office systolic and/or diastolic BP, change in mean ambulatory blood pressure, the proportion of patients reaching target BP, and adverse events including mortality or cardiovascular morbidity or related to treatment with antihypertensive agents. DISCUSSION This review will help to determine if self-monitoring of blood pressure, with or without co-interventions, is effective in lowering blood pressure. Results will be available for conference.
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Affiliation(s)
- Róisín Doogue
- Department of General Practice, School of Medicine, University of Limerick, Limerick, Ireland
| | - Peter Hayes
- Department of General Practice, School of Medicine, University of Limerick, Limerick, Ireland
| | - Katherine Tucker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tom Fahey
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ali Sheikhi
- Health Research Institute, University of Limerick, Limerick, Ireland
| | | | - Liam Glynn
- Department of General Practice, School of Medicine, University of Limerick, Limerick, Ireland
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11
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Archer L, Koshiaris C, Lay-Flurrie S, Snell KIE, Riley RD, Stevens R, Banerjee A, Usher-Smith JA, Clegg A, Payne RA, Hobbs FDR, McManus RJ, Sheppard JP. Development and external validation of a risk prediction model for falls in patients with an indication for antihypertensive treatment: retrospective cohort study. BMJ 2022; 379:e070918. [PMID: 36347531 PMCID: PMC9641577 DOI: 10.1136/bmj-2022-070918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To develop and externally validate the STRAtifying Treatments In the multi-morbid Frail elderlY (STRATIFY)-Falls clinical prediction model to identify the risk of hospital admission or death from a fall in patients with an indication for antihypertensive treatment. DESIGN Retrospective cohort study. SETTING Primary care data from electronic health records contained within the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS Patients aged 40 years or older with at least one blood pressure measurement between 130 mm Hg and 179 mm Hg. MAIN OUTCOME MEASURE First serious fall, defined as hospital admission or death with a primary diagnosis of a fall within 10 years of the index date (12 months after cohort entry). Model development was conducted using a Fine-Gray approach in data from CPRD GOLD, accounting for the competing risk of death from other causes, with subsequent recalibration at one, five, and 10 years using pseudo values. External validation was conducted using data from CPRD Aurum, with performance assessed through calibration curves and the observed to expected ratio, C statistic, and D statistic, pooled across general practices, and clinical utility using decision curve analysis at thresholds around 10%. RESULTS Analysis included 1 772 600 patients (experiencing 62 691 serious falls) from CPRD GOLD used in model development, and 3 805 366 (experiencing 206 956 serious falls) from CPRD Aurum in the external validation. The final model consisted of 24 predictors, including age, sex, ethnicity, alcohol consumption, living in an area of high social deprivation, a history of falls, multiple sclerosis, and prescriptions of antihypertensives, antidepressants, hypnotics, and anxiolytics. Upon external validation, the recalibrated model showed good discrimination, with pooled C statistics of 0.833 (95% confidence interval 0.831 to 0.835) and 0.843 (0.841 to 0.844) at five and 10 years, respectively. Original model calibration was poor on visual inspection and although this was improved with recalibration, under-prediction of risk remained (observed to expected ratio at 10 years 1.839, 95% confidence interval 1.811 to 1.865). Nevertheless, decision curve analysis suggests potential clinical utility, with net benefit larger than other strategies. CONCLUSIONS This prediction model uses commonly recorded clinical characteristics and distinguishes well between patients at high and low risk of falls in the next 1-10 years. Although miscalibration was evident on external validation, the model still had potential clinical utility around risk thresholds of 10% and so could be useful in routine clinical practice to help identify those at high risk of falls who might benefit from closer monitoring or early intervention to prevent future falls. Further studies are needed to explore the appropriate thresholds that maximise the model's clinical utility and cost effectiveness.
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Affiliation(s)
- Lucinda Archer
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Kym I E Snell
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Richard D Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, University of Leeds, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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12
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Chandna A, Mahajan R, Gautam P, Mwandigha L, Kumar P, Varghese GM, Koshiaris C, Lubell Y, Burza S. Host biomarkers reflect prognosis in patients presenting with moderate Covid-19 – a prospective cohort study. Open Forum Infect Dis 2022; 9:ofac526. [PMID: 36320192 PMCID: PMC9605705 DOI: 10.1093/ofid/ofac526] [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] [Received: 07/11/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Efficient resource allocation is essential for effective pandemic response. We measured host biomarkers in 420 patients presenting with moderate Covid-19 and found that different biomarkers predict distinct clinical outcomes. IL-1ra, IL-6, IL-10, and IL-8 exhibit dose-response relationships with subsequent disease progression and could potentially be useful for multiple use-cases.
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Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children , Siem Reap , Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford , Oxford , UK
| | | | - Priyanka Gautam
- Department of Infectious Diseases, Christian Medical College , Vellore , India
| | - Lazaro Mwandigha
- Nuffield Department of Primary Care Health Sciences, University of Oxford , Oxford , UK
| | - Pragya Kumar
- Department of Community & Family Medicine, All India Institute of Medical Sciences , Patna , India
| | - George M Varghese
- Department of Infectious Diseases, Christian Medical College , Vellore , India
| | | | - Yoel Lubell
- Centre for Tropical Medicine & Global Health, University of Oxford , Oxford , UK
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University , Bangkok , Thailand
| | - Sakib Burza
- Médecins Sans Frontières , New Delhi , India
- Department of Clinical Research, London School of Hygiene & Tropical Medicine , London , UK
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13
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Chandna A, Mahajan R, Gautam P, Mwandigha L, Gunasekaran K, Bhusan D, Cheung ATL, Day N, Dittrich S, Dondorp A, Geevar T, Ghattamaneni SR, Hussain S, Jimenez C, Karthikeyan R, Kumar S, Kumar S, Kumar V, Kundu D, Lakshmanan A, Manesh A, Menggred C, Moorthy M, Osborn J, Richard-Greenblatt M, Sharma S, Singh VK, Singh VK, Suri J, Suzuki S, Tubprasert J, Turner P, Villanueva AMG, Waithira N, Kumar P, Varghese GM, Koshiaris C, Lubell Y, Burza S. Facilitating Safe Discharge Through Predicting Disease Progression in Moderate Coronavirus Disease 2019 (COVID-19): A Prospective Cohort Study to Develop and Validate a Clinical Prediction Model in Resource-Limited Settings. Clin Infect Dis 2022; 75:e368-e379. [PMID: 35323932 PMCID: PMC9129107 DOI: 10.1093/cid/ciac224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In locations where few people have received coronavirus disease 2019 (COVID-19) vaccines, health systems remain vulnerable to surges in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Tools to identify patients suitable for community-based management are urgently needed. METHODS We prospectively recruited adults presenting to 2 hospitals in India with moderate symptoms of laboratory-confirmed COVID-19 to develop and validate a clinical prediction model to rule out progression to supplemental oxygen requirement. The primary outcome was defined as any of the following: SpO2 < 94%; respiratory rate > 30 BPM; SpO2/FiO2 < 400; or death. We specified a priori that each model would contain three clinical parameters (age, sex, and SpO2) and 1 of 7 shortlisted biochemical biomarkers measurable using commercially available rapid tests (C-reactive protein [CRP], D-dimer, interleukin 6 [IL-6], neutrophil-to-lymphocyte ratio [NLR], procalcitonin [PCT], soluble triggering receptor expressed on myeloid cell-1 [sTREM-1], or soluble urokinase plasminogen activator receptor [suPAR]), to ensure the models would be suitable for resource-limited settings. We evaluated discrimination, calibration, and clinical utility of the models in a held-out temporal external validation cohort. RESULTS In total, 426 participants were recruited, of whom 89 (21.0%) met the primary outcome; 257 participants comprised the development cohort, and 166 comprised the validation cohort. The 3 models containing NLR, suPAR, or IL-6 demonstrated promising discrimination (c-statistics: 0.72-0.74) and calibration (calibration slopes: 1.01-1.05) in the validation cohort and provided greater utility than a model containing the clinical parameters alone. CONCLUSIONS We present 3 clinical prediction models that could help clinicians identify patients with moderate COVID-19 suitable for community-based management. The models are readily implementable and of particular relevance for locations with limited resources.
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Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Priyanka Gautam
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Lazaro Mwandigha
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Divendu Bhusan
- Department of Internal Medicine, All India Institute of Medical Sciences, Patna, India
| | - Arthur T L Cheung
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Nicholas Day
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Sabine Dittrich
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Foundation for Innovative Diagnostics, Geneva, Switzerland
| | - Arjen Dondorp
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Tulasi Geevar
- Department of Transfusion Medicine & Immunohaematology, Christian Medical College, Vellore, India
| | | | | | | | - Rohini Karthikeyan
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Sanjeev Kumar
- Department of Cardiothoracic & Vascular Surgery, All India Institute of Medical Sciences, Patna, India
| | - Shiril Kumar
- Department of Virology, Rajendra Memorial Research Institute of Medical Sciences, Patna, India
| | | | - Debasree Kundu
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | | | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Chonticha Menggred
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Mahesh Moorthy
- Department of Clinical Virology, Christian Medical College, Vellore, India
| | | | | | - Sadhana Sharma
- Department of Biochemistry, All India Institute of Medical Sciences, Patna, India
| | - Veena K Singh
- Department of Burns & Plastic Surgery, All India Institute of Medical Sciences, Patna, India
| | | | | | - Shuichi Suzuki
- School of Tropical Medicine & Global Health, Nagasaki University, Nagasaki, Japan
| | - Jaruwan Tubprasert
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Naomi Waithira
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Pragya Kumar
- Department of Community & Family Medicine, All India Institute of Medical Sciences, Patna, Indiaand
| | - George M Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Yoel Lubell
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Sakib Burza
- Médecins Sans Frontières, New Delhi, India
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Cai T, Koshiaris C, Hirst J, Hobbs F, Mcmanus R, Sheppard J. Predicting individual risk of muscle disorders in patients eligible for statin treatment: Stratify-statinmd model derivation using data from electronic health records. Atherosclerosis 2022. [DOI: 10.1016/j.atherosclerosis.2022.06.853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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McFadden E, Lay-Flurrie S, Koshiaris C, Richards GC, Heneghan C. The Long-Term Impact of Vaginal Surgical Mesh Devices in UK Primary Care: A Cohort Study in the Clinical Practice Research Datalink. Clin Epidemiol 2021; 13:1167-1180. [PMID: 35002329 PMCID: PMC8728093 DOI: 10.2147/clep.s333775] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) may be treated with surgical mesh devices; evidence of their long-term complications is lacking. PATIENTS AND METHODS Rates of diagnoses of depression, anxiety or self-harm (composite measure) and sexual dysfunction, and rates of prescriptions for antibiotics and opioids were estimated in women with and without mesh surgery, with a diagnostic SUI/POP code, registered in the Clinical Practice Research Datalink (CPRD) gold database. RESULTS There were 220,544 women eligible for inclusion; 74% (n = 162,687) had SUI, 37% (n = 82,123) had POP, and 11% (n = 24,266) had both. Women undergoing mesh surgery for SUI or POP had about 1.1 times higher rates of antibiotic use. Women with no previous history of the outcome, who underwent mesh surgery had 2.43 (95% CI 2.19-2.70) and 1.47 (95% CI 1.19-1.81) times higher rates of depression, anxiety, or self-harm, 1.88 (95% CI 1.50-2.36) and 1.64 (95% CI 1.02-2.63) times higher rates of sexual dysfunction and 1.40 (95% CI 1.26-1.56) and 1.23 (95% CI 1.01-1.49) times higher opioid use for SUI and POP, respectively. Women with a history of depression, anxiety and self-harm had 0.3 times lower rates of these outcomes with SUI or POP mesh surgery (HR for SUI 0.70 (95% CI 0.67-0.73), HR for POP 0.72 (95% CI 0.65-0.79)). Women with a history of opioid use who had POP mesh surgery had about 0.09 times lower rates (HR 0.91 (95% CI 0.86-0.96)) of prescriptions. Negative control outcome analyses showed no evidence of an association between asthma consultations and mesh surgery in women with POP, but the rate was 0.09 times lower (HR 0.91 (95% CI 0.87-0.94)) in women with SUI mesh surgery, suggesting that study results are subject to some residual confounding. CONCLUSION Mesh surgery was associated with poor mental and sexual health outcomes, alongside increased opioid and antibiotic use, in women with no history of these outcomes and improved mental health, and lower opioid use, in women with a previous history of these outcomes. Although our results suggest an influence of residual confounding, careful consideration of the benefits and risk of mesh surgery for women with SUI or POP on an individual basis is required.
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Affiliation(s)
- Emily McFadden
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Lay-Flurrie
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- EMEA Real World Methods and Evidence Generation, IQVIA, London, UK
| | - Constantinos Koshiaris
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Georgia C Richards
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Global Centre on Healthcare and Urbanisation, Kellogg College, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Global Centre on Healthcare and Urbanisation, Kellogg College, University of Oxford, Oxford, UK
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16
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Lee JJ, Koshiaris C, Hobbs FR, Sheppard JP. Beyond COVID-19: respiratory infection and cardiovascular events. Br J Gen Pract 2021; 71:342-343. [PMID: 34326074 PMCID: PMC8312665 DOI: 10.3399/bjgp21x716477] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Joseph J Lee
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | | | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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17
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Cai T, Abel L, Langford O, Monaghan G, Aronson JK, Stevens RJ, Lay-Flurrie S, Koshiaris C, McManus RJ, Hobbs FDR, Sheppard JP. Associations between statins and adverse events in primary prevention of cardiovascular disease: systematic review with pairwise, network, and dose-response meta-analyses. BMJ 2021; 374:n1537. [PMID: 34261627 PMCID: PMC8279037 DOI: 10.1136/bmj.n1537] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the associations between statins and adverse events in primary prevention of cardiovascular disease and to examine how the associations vary by type and dosage of statins. DESIGN Systematic review and meta-analysis. DATA SOURCES Studies were identified from previous systematic reviews and searched in Medline, Embase, and the Cochrane Central Register of Controlled Trials, up to August 2020. REVIEW METHODS Randomised controlled trials in adults without a history of cardiovascular disease that compared statins with non-statin controls or compared different types or dosages of statins were included. MAIN OUTCOME MEASURES Primary outcomes were common adverse events: self-reported muscle symptoms, clinically confirmed muscle disorders, liver dysfunction, renal insufficiency, diabetes, and eye conditions. Secondary outcomes included myocardial infarction, stroke, and death from cardiovascular disease as measures of efficacy. DATA SYNTHESIS A pairwise meta-analysis was conducted to calculate odds ratios and 95% confidence intervals for each outcome between statins and non-statin controls, and the absolute risk difference in the number of events per 10 000 patients treated for a year was estimated. A network meta-analysis was performed to compare the adverse effects of different types of statins. An Emax model based meta-analysis was used to examine the dose-response relationships of the adverse effects of each statin. RESULTS 62 trials were included, with 120 456 participants followed up for an average of 3.9 years. Statins were associated with an increased risk of self-reported muscle symptoms (21 trials, odds ratio 1.06 (95% confidence interval 1.01 to 1.13); absolute risk difference 15 (95% confidence interval 1 to 29)), liver dysfunction (21 trials, odds ratio 1.33 (1.12 to 1.58); absolute risk difference 8 (3 to 14)), renal insufficiency (eight trials, odds ratio 1.14 (1.01 to 1.28); absolute risk difference 12 (1 to 24)), and eye conditions (six trials, odds ratio 1.23 (1.04 to 1.47); absolute risk difference 14 (2 to 29)) but were not associated with clinically confirmed muscle disorders or diabetes. The increased risks did not outweigh the reduction in the risk of major cardiovascular events. Atorvastatin, lovastatin, and rosuvastatin were individually associated with some adverse events, but few significant differences were found between types of statins. An Emax dose-response relationship was identified for the effect of atorvastatin on liver dysfunction, but the dose-response relationships for the other statins and adverse effects were inconclusive. CONCLUSIONS For primary prevention of cardiovascular disease, the risk of adverse events attributable to statins was low and did not outweigh their efficacy in preventing cardiovascular disease, suggesting that the benefit-to-harm balance of statins is generally favourable. Evidence to support tailoring the type or dosage of statins to account for safety concerns before starting treatment was limited. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020169955.
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Affiliation(s)
- Ting Cai
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Oliver Langford
- Alzheimer's Therapeutic Research Institute, University of Southern California, Los Angeles, USA
| | - Genevieve Monaghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard J Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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18
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van der Veen RS, Lee JJ, McManus RJ, Hobbs RFD, Mahtani KR, Koshiaris C, Sheppard JP. The health impacts of preventive cardiovascular medication reduction on older populations: protocol for a systematic review and meta-analysis. Syst Rev 2021; 10:185. [PMID: 34167593 PMCID: PMC8229162 DOI: 10.1186/s13643-021-01741-2] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 06/09/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Polypharmacy is inevitable and appropriate for many conditions, but in some cases, it can be problematic resulting in an increased risk of harm and reduced quality of life. There has been an increasing interest to reduce cardioprotective medications in older adults to potentially reduce the risk of harm due to treatment; however, there is no evidence on safety and efficacy to support this practice currently. This paper describes a protocol for a systematic review on the safety and efficacy of reducing cardioprotective medication in older populations. METHODS MEDLINE (PubMed), Embase (Ovid), and CENTRAL (Cochrane Central Register of Controlled Trials) will be searched from their inception onwards for relevant studies. Randomised controlled trials and non-randomised studies on interventions (prospective, retrospective cohort, case-control) conducted in older adults (75 years or older) examining reduction of cardioprotective medications will be included. The primary outcome of this study will be all-cause hospitalisation. Secondary outcome variables of interest are all-cause hospitalisation, mortality, quality of life, serious adverse events, major adverse cardiovascular events, falls, fractures, cognitive functioning, bleeding events, renal functioning, medication burden, drug reinstatement, time-in-hospital, and frailty status. Two reviewers will independently screen all citations, full-text articles, and extract data. Confidence in cumulative evidence will be assessed using the GRADE approach; the risk of bias will be assessed by the RoB-II tool for randomised controlled studies and ROBINS-I for non-randomised studies. Where sufficient data are available, we will conduct a random effects meta-analysis by combining the outcomes of the included studies. Sub-group analysis and meta-regression are planned to assess the potential harms and risks of different drug classes and the impacts in different patient populations (e.g. sex, cognitive status, renal status, and age). DISCUSSION The study will be a comprehensive review on all published articles identified using our search strategy on the safety and efficacy of cardioprotective medication reduction in the older population. The findings will be crucial to inform clinicians on potential health outcomes of reducing cardiovascular medication in the elderly. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020208223.
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Affiliation(s)
- Rik S van der Veen
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2 6GG, UK.
| | - Joseph J Lee
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Richard F D Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2 6GG, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2 6GG, UK
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19
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Lear A, Patel N, Mullen C, Simonson M, Leone V, Koshiaris C, Nunan D. Screening electrocardiogram in young athletes and military members: a systematic review and meta-analysis. J Athl Train 2021; 57:444-451. [PMID: 34038955 PMCID: PMC9205557 DOI: 10.4085/1062-6050-0746.20] [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] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the effect of electrocardiogram (ECG) screening on prevention of sudden cardiac arrest and death (SCA/D) in young athletes and military members. DATA SOURCES MEDLINE, Embase, Cochrane CENTRAL, Web of Science, BIOSIS, Scopus, SPORT discus, PEDro, and clinicaltrials.gov were searched from inception to dates between 2/21/19 and 7/29/19. STUDY SELECTION Randomized and non-randomized controlled trials, where pre-participation examination including ECG was the primary intervention used to screen athletes or military 40 years of age or younger. Accepted controls were no screening, usual care, or pre-participation examination without ECG. 3 published studies , and one conference abstract were identified for inclusion. DATA EXTRACTION In all four studies, risk of bias was assessed with the Cochrane risk of bias tool, and found to be generally high. Two studies had data extracted for random effects meta-analysis, and the remaining study and conference abstract were included in narrative review. Overall quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Data Synthesis: Four non-randomized studies (11,689,172 participants) were included, all at high risk of bias. Pooled data from two studies (n= 3,869,274; very low quality evidence) observed an inconclusive 42% relative decrease in risk of sudden cardiac death (RR 0.58; 95% CI 0.23, 1.45), equating to an absolute risk reduction of .0016% The findings were consistent with a potential 67% relative decrease to a 45% relative increased risk in participants screened with ECG. Heterogeneity was found to be high as measured with I2 statistic (71%). Data from the remaining study and abstract were similarly inconclusive. CONCLUSION Existing evidence for the effect of ECG screening is inconclusive and of very low quality. Our meta-analysis observed that screening ECG may result in considerable benefit or harm to participants. Higher quality studies are needed to reduce this uncertainty. PROSPERO Registration: CRD42019125560.
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Affiliation(s)
- Aaron Lear
- Cleveland Clinic Akron General, Akron, OH USA
| | | | | | | | - Vince Leone
- Northeast Ohio Medical University (NEOMED), Akron, OH USA
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20
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Lear A, Patel N, Mullen C, Simonson M, Leone V, Koshiaris C, Nunan D. Incidence of sudden cardiac arrest and death in young athletes and military members: a systematic review and meta-analysis. J Athl Train 2021; 57:431-443. [PMID: 34038947 PMCID: PMC9205551 DOI: 10.4085/1062-6050-0748.20] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The goals of this review are to evaluate the quality of the evidence on the incidence of sudden cardiac arrest and death (SCA/D) in athletes and military members; and to estimate annual incidence of SCA/D. DATA SOURCES MEDLINE, Embase, Cochrane CENTRAL, Web of Science, BIOSIS, Scopus, SPORT discus, PEDro, and clinicaltrials.gov were searched from inception to dates between 2/21/19-7/29/19. STUDY SELECTION Studies which reported incidence of SCA/D or both in athletes, or military members under age 40 were eligible for inclusion. 40 studies were identified for inclusion Data Extraction: Risk of bias was assessed using a validated, customized tool for prevalence studies in all included studies. 12 were found to be low ROB, with the remaining 28 moderate or high ROB. Data was extracted for narrative review, and meta-analysis. DATA SYNTHESIS Random-effects meta-analysis was performed in studies judged to be low risk of bias in two separate categories: 5 studies on regional or national level data including athletes at all levels, and both sexes included 130 events of SCD, with a total of 11,272,560 athlete years showing a cumulative incidence rate of 0.98 [95%CI: 0.62, 1.53] per 100,000 athlete years, with high heterogeneity with I2 of 78%; 3 Studies on competitive athletes aged 14 to 25 were combined, and included 183 events, and 17,798758 athlete years showing an incidence rate of 1.91[95%CI: 0.71; 5.14] per 100,000 athlete years with high heterogeneity with I2 of 97%. The remaining low risk of bias studies were in military members, and were not synthesized. CONCLUSION The worldwide incidence of SCD is a rare event. Low risk of bias studies indicate incidence to be below 2 per 100,000 athlete years. Overall, the quality of the evidence available is low, but there are high quality individual studies to inform the question of incidence levels. PROSPERO Registration: CRD42019125560.
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Affiliation(s)
- Aaron Lear
- Cleveland Clinic Akron General, Akron, OH USA
| | | | | | | | - Vince Leone
- Northeast Ohio Medical University (NEOMED), Akron, OH USA
| | | | - David Nunan
- University of Oxford, Oxford, UK Twitter: @dnunan79
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21
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Koshiaris C, Van den Bruel A, Nicholson BD, Lay-Flurrie S, Hobbs FR, Oke JL. Clinical prediction tools to identify patients at highest risk of myeloma in primary care: a retrospective open cohort study. Br J Gen Pract 2021; 71:e347-e355. [PMID: 33824161 PMCID: PMC8049204 DOI: 10.3399/bjgp.2020.0697] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/01/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patients with myeloma experience substantial delays in their diagnosis, which can adversely affect their prognosis. AIM To generate a clinical prediction rule to identify primary care patients who are at highest risk of myeloma. DESIGN AND SETTING Retrospective open cohort study using electronic health records data from the UK's Clinical Practice Research Datalink (CPRD) between 1 January 2000 and 1 January 2014. METHOD Patients from the CPRD were included in the study if they were aged ≥40 years, had two full blood counts within a year, and had no previous diagnosis of myeloma. Cases of myeloma were identified in the following 2 years. Derivation and external validation datasets were created based on geographical region. Prediction equations were estimated using Cox proportional hazards models including patient characteristics, symptoms, and blood test results. Calibration, discrimination, and clinical utility were evaluated in the validation set. RESULTS Of 1 281 926 eligible patients, 737 (0.06%) were diagnosed with myeloma within 2 years. Independent predictors of myeloma included: older age; male sex; back, chest and rib pain; nosebleeds; low haemoglobin, platelets, and white cell count; and raised mean corpuscular volume, calcium, and erythrocyte sedimentation rate. A model including symptoms and full blood count had an area under the curve of 0.84 (95% CI = 0.81 to 0.87) and sensitivity of 62% (95% CI = 55% to 68%) at the highest risk decile. The corresponding statistics for a second model, which also included calcium and inflammatory markers, were an area under the curve of 0.87 (95% CI = 0.84 to 0.90) and sensitivity of 72% (95% CI = 66% to 78%). CONCLUSION The implementation of these prediction rules would highlight the possibility of myeloma in patients where GPs do not suspect myeloma. Future research should focus on the prospective evaluation of further external validity and the impact on clinical practice.
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Affiliation(s)
| | | | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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22
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Albasri A, Hattle M, Koshiaris C, Dunnigan A, Paxton B, Fox SE, Smith M, Archer L, Levis B, Payne RA, Riley RD, Roberts N, Snell KIE, Lay-Flurrie S, Usher-Smith J, Stevens R, Hobbs FDR, McManus RJ, Sheppard JP. Association between antihypertensive treatment and adverse events: systematic review and meta-analysis. BMJ 2021; 372:n189. [PMID: 33568342 PMCID: PMC7873715 DOI: 10.1136/bmj.n189] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the association between antihypertensive treatment and specific adverse events. DESIGN Systematic review and meta-analysis. ELIGIBILITY CRITERIA Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up. INFORMATION SOURCES Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020. MAIN OUTCOME MEASURES The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ2). RESULTS Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ2=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ2=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ2=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ2=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ2=0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction. CONCLUSIONS This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function. REGISTRATION PROSPERO CRD42018116860.
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Affiliation(s)
- Ali Albasri
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | | | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Anna Dunnigan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ben Paxton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Emma Fox
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Margaret Smith
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | | | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
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23
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Nicholson BD, Hayward G, Turner PJ, Lee JJ, Deeks A, Logan M, Moore A, Seeley A, Fanshawe T, Oke J, Koshiaris C, Sheppard JP, Hoang U, Parimalanathan V, Edwards G, Liyange H, Sherlock J, Byford R, Zambon M, Ellis J, Bernal JL, Amirthalingam G, Linley E, Borrow R, Howsam G, Baines S, Ferreira F, de Lusignan S, Perera R, Hobbs FDR. Rapid community point-of-care testing for COVID-19 (RAPTOR-C19): protocol for a platform diagnostic study. Diagn Progn Res 2021; 5:4. [PMID: 33557927 PMCID: PMC7868893 DOI: 10.1186/s41512-021-00093-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/18/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of RApid community Point-of-care Testing fOR COVID-19 (RAPTOR-C19) is to assess the diagnostic accuracy of multiple current and emerging point-of-care tests (POCTs) for active and past SARS-CoV2 infection in the community setting. RAPTOR-C19 will provide the community testbed to the COVID-19 National DiagnOstic Research and Evaluation Platform (CONDOR). METHODS RAPTOR-C19 incorporates a series of prospective observational parallel diagnostic accuracy studies of SARS-CoV2 POCTs against laboratory and composite reference standards in patients with suspected current or past SARS-CoV2 infection attending community settings. Adults and children with suspected current SARS-CoV2 infection who are having an oropharyngeal/nasopharyngeal (OP/NP) swab for laboratory SARS-CoV2 reverse transcriptase Digital/Real-Time Polymerase Chain Reaction (d/rRT-PCR) as part of clinical care or community-based testing will be invited to participate. Adults (≥ 16 years) with suspected past symptomatic infection will also be recruited. Asymptomatic individuals will not be eligible. At the baseline visit, all participants will be asked to submit samples for at least one candidate point-of-care test (POCT) being evaluated (index test/s) as well as an OP/NP swab for laboratory SARS-CoV2 RT-PCR performed by Public Health England (PHE) (reference standard for current infection). Adults will also be asked for a blood sample for laboratory SARS-CoV-2 antibody testing by PHE (reference standard for past infection), where feasible adults will be invited to attend a second visit at 28 days for repeat antibody testing. Additional study data (e.g. demographics, symptoms, observations, household contacts) will be captured electronically. Sensitivity, specificity, positive, and negative predictive values for each POCT will be calculated with exact 95% confidence intervals when compared to the reference standard. POCTs will also be compared to composite reference standards constructed using paired antibody test results, patient reported outcomes, linked electronic health records for outcomes related to COVID-19 such as hospitalisation or death, and other test results. DISCUSSION High-performing POCTs for community use could be transformational. Real-time results could lead to personal and public health impacts such as reducing onward household transmission of SARS-CoV2 infection, improving surveillance of health and social care staff, contributing to accurate prevalence estimates, and understanding of SARS-CoV2 transmission dynamics in the population. In contrast, poorly performing POCTs could have negative effects, so it is necessary to undertake community-based diagnostic accuracy evaluations before rolling these out. TRIAL REGISTRATION ISRCTN, ISRCTN14226970.
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Affiliation(s)
- Brian D. Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Philip J. Turner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Joseph J. Lee
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Alexandra Deeks
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Mary Logan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Abigail Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Anna Seeley
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Thomas Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Jason Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - James P. Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Uy Hoang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Vaishnavi Parimalanathan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - George Edwards
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Harshana Liyange
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Julian Sherlock
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Rachel Byford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Maria Zambon
- National Infection Service, Public Health England, London, UK
| | - Joanna Ellis
- National Infection Service, Public Health England, London, UK
| | | | | | - Ezra Linley
- National Infection Service, Public Health England, London, UK
| | - Ray Borrow
- National Infection Service, Public Health England, London, UK
| | - Gary Howsam
- Royal College of General Practitioners, 30 Euston Square, London, NW1 2FB UK
| | - Sophie Baines
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Filipa Ferreira
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - F. D. Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
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Koutoukidis DA, Koshiaris C, Henry JA, Noreik M, Morris E, Manoharan I, Tudor K, Bodenham E, Dunnigan A, Jebb SA, Aveyard P. The effect of the magnitude of weight loss on non-alcoholic fatty liver disease: A systematic review and meta-analysis. Metabolism 2021; 115:154455. [PMID: 33259835 DOI: 10.1016/j.metabol.2020.154455] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/27/2020] [Accepted: 11/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Trials show that weight loss interventions improve biomarkers of non-alcoholic fatty liver disease (NAFLD), but it is unclear if a dose-response relationship exists. OBJECTIVE We aimed to quantify the dose-response relationship between the magnitude of weight loss and improvements in NAFLD. METHODS Nine databases and trial registries were searched until October 2020. Single-arm, non-randomized comparative, or randomized trials of weight loss interventions (behavioral weight loss programs [BWLPs], pharmacotherapy, or bariatric surgery) in people with NAFLD were eligible for inclusion if they reported an association between changes in weight and changes in blood, radiological, or histological biomarkers of liver disease. The review followed Cochrane methods and the risk of bias was assessed using the Newcastle-Ottawa scale. Pooled unstandardized b coefficients were calculated using random-effect meta-analyses. RESULTS Forty-three studies (BWMPs: 26, pharmacotherapy: 9, surgery: 8) with 2809 participants were included. The median follow-up was 6 (interquartile range: 6) months. The direction of effect was generally consistent but the estimates imprecise. Every 1 kg of weight lost was associated with a 0.83-unit (95% CI: 0.53 to 1.14, p < 0.0001, I2 = 92%, n = 18) reduction in alanine aminotransferase (U/L), a 0.56-unit (95% CI: 0.32 to 0.79, p < 0.0001, I2 = 68%, n = 11) reduction in aspartate transaminase (U/L), and a 0.77 percentage point (95% CI: 0.51 to 1.03, p < 0.0001, I2 = 72%, n = 11) reduction in steatosis assessed by radiology or histology. There was evidence of a dose-response relationship with liver inflammation, ballooning, and resolution of NAFLD or NASH, but limited evidence of a dose-response relationship with fibrosis or NAFLD activity score. On average, the risk of bias for selection and outcome was medium and low, respectively. CONCLUSION Clinically significant improvements in NAFLD are achieved even with modest weight loss, but greater weight loss is associated with greater improvements. Embedding support for formal weight loss programs as part of the care pathway for the treatment of NAFLD could reduce the burden of disease. PROSPERO CRD42018093676.
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Affiliation(s)
- Dimitrios A Koutoukidis
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; NIHR Oxford Biomedical Research Centre, Oxford OX2 6GG, UK.
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK.
| | - John A Henry
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK.
| | - Michaela Noreik
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; NIHR Oxford Biomedical Research Centre, Oxford OX2 6GG, UK.
| | - Elizabeth Morris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK.
| | - Indrani Manoharan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK.
| | - Kate Tudor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; NIHR Oxford Biomedical Research Centre, Oxford OX2 6GG, UK.
| | - Emma Bodenham
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Anna Dunnigan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; NIHR Oxford Biomedical Research Centre, Oxford OX2 6GG, UK.
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; NIHR Oxford Biomedical Research Centre, Oxford OX2 6GG, UK.
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25
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Chandna A, Aderie EM, Ahmad R, Arguni E, Ashley EA, Cope T, Dat VQ, Day NPJ, Dondorp AM, Illanes V, De Jesus J, Jimenez C, Kain K, Suy K, Koshiaris C, Lasry E, Mayxay M, Mondal D, Perera R, Pongvongsa T, Rattanavong S, Rekart M, Richard-Greenblatt M, Shomik M, Souvannasing P, Tallo V, Turner C, Turner P, Waithira N, Watson JA, Yosia M, Burza S, Lubell Y. Prediction of disease severity in young children presenting with acute febrile illness in resource-limited settings: a protocol for a prospective observational study. BMJ Open 2021; 11:e045826. [PMID: 33495264 PMCID: PMC7839891 DOI: 10.1136/bmjopen-2020-045826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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] [Received: 10/13/2020] [Revised: 12/03/2020] [Accepted: 01/11/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION In rural and difficult-to-access settings, early and accurate recognition of febrile children at risk of progressing to serious illness could contribute to improved patient outcomes and better resource allocation. This study aims to develop a prognostic clinical prediction tool to assist community healthcare providers identify febrile children who might benefit from referral or admission for facility-based medical care. METHODS AND ANALYSIS This prospective observational study will recruit at least 4900 paediatric inpatients and outpatients under the age of 5 years presenting with an acute febrile illness to seven hospitals in six countries across Asia. A venous blood sample and nasopharyngeal swab is collected from each participant and detailed clinical data recorded at presentation, and each day for the first 48 hours of admission for inpatients. Multianalyte assays are performed at reference laboratories to measure a panel of host biomarkers, as well as targeted aetiological investigations for common bacterial and viral pathogens. Clinical outcome is ascertained on day 2 and day 28.Presenting syndromes, clinical outcomes and aetiology of acute febrile illness will be described and compared across sites. Following the latest guidance in prediction model building, a prognostic clinical prediction model, combining simple clinical features and measurements of host biomarkers, will be derived and geographically externally validated. The performance of the model will be evaluated in specific presenting clinical syndromes and fever aetiologies. ETHICS AND DISSEMINATION The study has received approval from all relevant international, national and institutional ethics committees. Written informed consent is provided by the caretaker of all participants. Results will be shared with local and national stakeholders, and disseminated via peer-reviewed open-access journals and scientific meetings. TRIAL REGISTRATION NUMBER NCT04285021.
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Affiliation(s)
- Arjun Chandna
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Endashaw M Aderie
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Riris Ahmad
- Centre for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Daerah Istimewa Yogyakart, Indonesia
| | - Eggi Arguni
- Centre for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Daerah Istimewa Yogyakart, Indonesia
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
| | - Tanya Cope
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Nicholas P J Day
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Arjen M Dondorp
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Victor Illanes
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Joanne De Jesus
- Clinical Trials, Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Carolina Jimenez
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Kevin Kain
- Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Keang Suy
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Angkor Hospital for Children, Siem Reap, Siem Reap, Cambodia
| | | | - Estrella Lasry
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Mayfong Mayxay
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Dinesh Mondal
- Centre for Nutrition and Food Security (CNFS), icddr,b, Dhaka, Dhaka, Bangladesh
| | - Rafael Perera
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tiengkham Pongvongsa
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
- Savannakhet Provincial Health Department, Savannakhet, Lao People's Democratic Republic
| | - Sayaphet Rattanavong
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
| | - Michael Rekart
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | | | - Mohammad Shomik
- Centre for Nutrition and Food Security (CNFS), icddr,b, Dhaka, Dhaka, Bangladesh
| | | | - Veronica Tallo
- Clinical Trials, Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Claudia Turner
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Angkor Hospital for Children, Siem Reap, Siem Reap, Cambodia
| | - Paul Turner
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Naomi Waithira
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - James A Watson
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Mikhael Yosia
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Sakib Burza
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
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26
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Doogue R, Hayes P, Tucker K, Fahey T, Sheikhi A, Koshiaris C, Glynn LG. Self-monitoring for improving control of blood pressure in patients with hypertension. Hippokratia 2021. [DOI: 10.1002/14651858.cd010311.pub2] [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] [Indexed: 11/09/2022]
Affiliation(s)
- Róisín Doogue
- Graduate Entry Medical School; University of Limerick; Limerick Ireland
| | - Peter Hayes
- Graduate Entry Medical School; University of Limerick; Limerick Ireland
| | - Katherine Tucker
- Department of Primary Care Health Sciences; University of Oxford; Oxford UK
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice; RCSI Medical School; Dublin 2 Ireland
| | - Ali Sheikhi
- Graduate Entry Medical School; University of Limerick; Limerick Ireland
| | | | - Liam G Glynn
- Graduate Entry Medical School; University of Limerick; Limerick Ireland
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27
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Chandna A, Tan R, Carter M, Van Den Bruel A, Verbakel J, Koshiaris C, Salim N, Lubell Y, Turner P, Keitel K. Predictors of disease severity in children presenting from the community with febrile illnesses: a systematic review of prognostic studies. BMJ Glob Health 2021; 6:e003451. [PMID: 33472837 PMCID: PMC7818824 DOI: 10.1136/bmjgh-2020-003451] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/26/2020] [Accepted: 12/19/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Early identification of children at risk of severe febrile illness can optimise referral, admission and treatment decisions, particularly in resource-limited settings. We aimed to identify prognostic clinical and laboratory factors that predict progression to severe disease in febrile children presenting from the community. METHODS We systematically reviewed publications retrieved from MEDLINE, Web of Science and Embase between 31 May 1999 and 30 April 2020, supplemented by hand search of reference lists and consultation with an expert Technical Advisory Panel. Studies evaluating prognostic factors or clinical prediction models in children presenting from the community with febrile illnesses were eligible. The primary outcome was any objective measure of disease severity ascertained within 30 days of enrolment. We calculated unadjusted likelihood ratios (LRs) for comparison of prognostic factors, and compared clinical prediction models using the area under the receiver operating characteristic curves (AUROCs). Risk of bias and applicability of studies were assessed using the Prediction Model Risk of Bias Assessment Tool and the Quality In Prognosis Studies tool. RESULTS Of 5949 articles identified, 18 studies evaluating 200 prognostic factors and 25 clinical prediction models in 24 530 children were included. Heterogeneity between studies precluded formal meta-analysis. Malnutrition (positive LR range 1.56-11.13), hypoxia (2.10-8.11), altered consciousness (1.24-14.02), and markers of acidosis (1.36-7.71) and poor peripheral perfusion (1.78-17.38) were the most common predictors of severe disease. Clinical prediction model performance varied widely (AUROC range 0.49-0.97). Concerns regarding applicability were identified and most studies were at high risk of bias. CONCLUSIONS Few studies address this important public health question. We identified prognostic factors from a wide range of geographic contexts that can help clinicians assess febrile children at risk of progressing to severe disease. Multicentre studies that include outpatients are required to explore generalisability and develop data-driven tools to support patient prioritisation and triage at the community level. PROSPERO REGISTRATION NUMBER CRD42019140542.
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Affiliation(s)
- Arjun Chandna
- Cambodia-Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Rainer Tan
- Unisanté Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Basel-Stadt, Switzerland
| | - Michael Carter
- Department of Women and Children's Health, King's College London, London, UK
| | - Ann Van Den Bruel
- Academic Centre of General Practice, University of Leuven, Leuven, Flanders, Belgium
| | - Jan Verbakel
- Academic Centre of General Practice, University of Leuven, Leuven, Flanders, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Nahya Salim
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Paul Turner
- Cambodia-Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Kristina Keitel
- Swiss Tropical and Public Health Institute, Basel, Basel-Stadt, Switzerland
- Division of Emergency Medicine, Department of Pediatrics, University Children's Hospital, Inselpital, University of Bern, Bern, Switzerland
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28
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Sheppard JP, Nicholson BD, Lee J, McGagh D, Sherlock J, Koshiaris C, Oke J, Jones NR, Hinton W, Armitage L, Van Hecke O, Lay-Flurrie S, Bankhead CR, Liyanage H, Williams J, Ferreira F, Feher MD, Ashworth AJ, Joy MP, de Lusignan S, Hobbs FDR. Association Between Blood Pressure Control and Coronavirus Disease 2019 Outcomes in 45 418 Symptomatic Patients With Hypertension: An Observational Cohort Study. Hypertension 2020; 77:846-855. [PMID: 33325240 PMCID: PMC7884248 DOI: 10.1161/hypertensionaha.120.16472] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [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] [Indexed: 01/08/2023]
Abstract
Supplemental Digital Content is available in the text. Hypertension has been identified as a risk factor for coronavirus disease 2019 (COVID-19) and associated adverse outcomes. This study examined the association between preinfection blood pressure (BP) control and COVID-19 outcomes using data from 460 general practices in England. Eligible patients were adults with hypertension who were tested or diagnosed with COVID-19. BP control was defined by the most recent BP reading within 24 months of the index date (January 1, 2020). BP was defined as controlled (<130/80 mm Hg), raised (130/80–139/89 mm Hg), stage 1 uncontrolled (140/90–159/99 mm Hg), or stage 2 uncontrolled (≥160/100 mm Hg). The primary outcome was death within 28 days of COVID-19 diagnosis. Secondary outcomes were COVID-19 diagnosis and COVID-19–related hospital admission. Multivariable logistic regression was used to examine the association between BP control and outcomes. Of the 45 418 patients (mean age, 67 years; 44.7% male) included, 11 950 (26.3%) had controlled BP. These patients were older, had more comorbidities, and had been diagnosed with hypertension for longer. A total of 4277 patients (9.4%) were diagnosed with COVID-19 and 877 died within 28 days. Individuals with stage 1 uncontrolled BP had lower odds of COVID-19 death (odds ratio, 0.76 [95% CI, 0.62–0.92]) compared with patients with well-controlled BP. There was no association between BP control and COVID-19 diagnosis or hospitalization. These findings suggest BP control may be associated with worse COVID-19 outcomes, possibly due to these patients having more advanced atherosclerosis and target organ damage. Such patients may need to consider adhering to stricter social distancing, to limit the impact of COVID-19 as future waves of the pandemic occur.
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Affiliation(s)
- James P Sheppard
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Brian D Nicholson
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Joseph Lee
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Dylan McGagh
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Julian Sherlock
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Constantinos Koshiaris
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Jason Oke
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Nicholas R Jones
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - William Hinton
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Laura Armitage
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Oliver Van Hecke
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Sarah Lay-Flurrie
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Clare R Bankhead
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Harshana Liyanage
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - John Williams
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Filipa Ferreira
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Michael D Feher
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | | | - Mark P Joy
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Simon de Lusignan
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - F D Richard Hobbs
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
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Richards GC, Aronson JK, Heneghan C, Mahtani KR, Koshiaris C, Persaud N. Relation between opioid consumption and inclusion of opioids in 137 national essential medicines lists. BMJ Glob Health 2020; 5:e003563. [PMID: 33173012 PMCID: PMC7656944 DOI: 10.1136/bmjgh-2020-003563] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/09/2020] [Accepted: 10/06/2020] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Opioids are deemed essential medicines by the World Health Organization (WHO). However, many countries have inadequate access to them. Whether including opioids in national essential medicines lists (EMLs) influences national opioid consumption has not been evaluated. METHODS We conducted a cross-sectional study to determine whether the listing of opioids in national EMLs was associated with consumption. We quantified the numbers and types of all opioids included in 137 national EMLs, for comparison with opioids in the WHO's Model List of Essential Medicines. Using the International Narcotics Control Board (INCB) consumption statistics for 2015-2017, we assessed the relation between annual mean opioid consumption (mg/person) and the numbers of opioids included in EMLs, controlling for region, population, healthcare expenditure, life expectancy, gross domestic product, human development and corruption. RESULTS Five opioids were included in the 20th edition of the WHO's Model List of Essential Medicines: codeine, fentanyl, loperamide, methadone and morphine. On average, countries' lists included significantly (p<0.05) more opioids than the WHO's Model List. However, there were wide variations in the numbers (median 6 opioids; IQR: 5-9) and types (n=33) of opioids included in national EMLs. Morphine (95%), fentanyl (83%) and codeine (69%) were the most commonly included opioids. Most national EMLs were out of date (median publication date: 2011, IQR: 2009-2013). After adjusting for country characteristics, there was no relation between mean opioid consumption and the number of opioids in EMLs. CONCLUSIONS Including opioids in national EMLs was not associated with consumption. National EMLs should be regularly updated to reflect the availability of opioids and the populations' needs for managing pain.
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Affiliation(s)
- Georgia C Richards
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Carl Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Kamal R Mahtani
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Nav Persaud
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
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Nicholson BD, Aveyard P, Price SJ, Hobbs FR, Koshiaris C, Hamilton W. Prioritising primary care patients with unexpected weight loss for cancer investigation: diagnostic accuracy study. BMJ 2020; 370:m2651. [PMID: 32816714 PMCID: PMC7424394 DOI: 10.1136/bmj.m2651] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To quantify the predictive value of unexpected weight loss (WL) for cancer according to patient's age, sex, smoking status, and concurrent clinical features (symptoms, signs, and abnormal blood test results). DESIGN Diagnostic accuracy study. SETTING Clinical Practice Research Datalink electronic health records data linked to the National Cancer Registration and Analysis Service in primary care, England. PARTICIPANTS 63 973 adults (≥18 years) with a code for unexpected WL from 1 January 2000 to 31 December 2012. MAIN OUTCOME MEASURES Cancer diagnosis in the six months after the earliest weight loss code (index date). Codes for additional clinical features were identified in the three months before to one month after the index date. Diagnostic accuracy measures included positive and negative likelihood ratios, positive predictive values, and diagnostic odds ratios. RESULTS Of 63 973 adults with unexpected WL, 37 215 (58.2%) were women, 33 167 (51.8%) were aged 60 years or older, and 16 793 (26.3%) were ever smokers. 908 (1.4%) had a diagnosis of cancer within six months of the index date, of whom 882 (97.1%) were aged 50 years or older. The positive predictive value for cancer was above the 3% threshold recommended by the National Institute for Health and Care Excellence for urgent investigation in male ever smokers aged 50 years or older, but not in women at any age. 10 additional clinical features were associated with cancer in men with unexpected WL, and 11 in women. Positive likelihood ratios in men ranged from 1.86 (95% confidence interval 1.32 to 2.62) for non-cardiac chest pain to 6.10 (3.44 to 10.79) for abdominal mass, and in women from 1.62 (1.15 to 2.29) for back pain to 20.9 (10.7 to 40.9) for jaundice. Abnormal blood test results associated with cancer included low albumin levels (4.67, 4.14 to 5.27) and raised values for platelets (4.57, 3.88 to 5.38), calcium (4.28, 3.05 to 6.02), total white cell count (3.76, 3.30 to 4.28), and C reactive protein (3.59, 3.31 to 3.89). However, no normal blood test result in isolation ruled out cancer. Clinical features co-occurring with unexpected WL were associated with multiple cancer sites. CONCLUSION The risk of cancer in adults with unexpected WL presenting to primary care is 2% or less and does not merit investigation under current UK guidelines. However, in male ever smokers aged 50 years or older and in patients with concurrent clinical features, the risk of cancer warrants referral for invasive investigation. Clinical features typically associated with specific cancer sites are markers of several cancer types when they occur with unexpected WL.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | | | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
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Nicholson BD, Hamilton W, Koshiaris C, Oke JL, Hobbs FDR, Aveyard P. The association between unexpected weight loss and cancer diagnosis in primary care: a matched cohort analysis of 65,000 presentations. Br J Cancer 2020; 122:1848-1856. [PMID: 32291391 PMCID: PMC7283307 DOI: 10.1038/s41416-020-0829-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [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: 09/28/2019] [Revised: 01/27/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023] Open
Abstract
Background We aimed to understand the time period of cancer diagnosis and the cancer types detected in primary care patients with unexpected weight loss (UWL) to inform cancer guidelines. Methods This retrospective matched cohort study used cancer registry linked electronic health records from the UK’s Clinical Practice Research Datalink from between 2000 and 2014. Univariable and multivariable time-to-event analyses examined the association between UWL, and all cancers combined, cancer site and stage. Results In all, 63,973 patients had UWL recorded, of whom 1375 (2.2%) were diagnosed with cancer within 2 years (days-to-diagnosis: mean 181; median 80). Men with UWL (HR 3.28 (2.88–3.73)) and women (1.87 (1.68–2.08)) were more likely than comparators to be diagnosed with cancer within 3 months. The association was greatest in men aged ≥50 years and women ≥70 years. The commonest cancers were pancreas, cancer of unknown primary, gastro-oesophageal, lymphoma, hepatobiliary, lung, bowel and renal-tract. The majority were late-stage, but there was some evidence of association with stage II and stage III cancers. In the 3–24 months after presenting with UWL, cancer diagnosis was less likely than in comparators. Conclusion UWL recorded in primary care is associated with a broad range of cancer sites of early and late-stage.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK.
| | | | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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Richards GC, Mahtani KR, Muthee TB, DeVito NJ, Koshiaris C, Aronson JK, Goldacre B, Heneghan CJ. Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis. BMC Med 2020; 18:68. [PMID: 32223746 PMCID: PMC7104520 DOI: 10.1186/s12916-020-01528-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 02/12/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care. METHODS We conducted a systematic review of observational studies in high-income countries that used patient-level primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNTH) calculation on factors when applicable. RESULTS We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I2 = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I2 = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I2 = 0%, NNTH 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I2 = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I2 = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care. CONCLUSIONS High doses of opioids are associated with greater risks of harms. Associated factors such as the co-prescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed. STUDY REGISTRATION PROSPERO, CRD42018088057.
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Affiliation(s)
- Georgia C Richards
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK. .,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Kamal R Mahtani
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Tonny B Muthee
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Nicholas J DeVito
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,EBMDatalab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Ben Goldacre
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,EBMDatalab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Carl J Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Gbinigie OA, Onakpoya IJ, Richards GC, Spencer EA, Koshiaris C, Bobrovitz N, Heneghan CJ. Biomarkers for diagnosing serious bacterial infections in older outpatients: a systematic review. BMC Geriatr 2019; 19:190. [PMID: 31315578 PMCID: PMC6637629 DOI: 10.1186/s12877-019-1205-0] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/09/2019] [Indexed: 11/24/2022] Open
Abstract
Background The value of biomarkers for diagnosing bacterial infections in older outpatients is uncertain and limited official guidance exists for clinicians in this area. The aim of this review is to critically appraise and evaluate biomarkers for diagnosing bacterial infections in older adults (aged 65 years and above). Methods We searched Medline, Embase, Web of Science and the Cochrane Library, from inception to January 2018. We included studies assessing the diagnostic accuracy of blood, urinary, and salivary biomarkers in diagnosing bacterial infections in older adults. The QUADAS-2 tool was used to assess study quality. Results We identified 11 eligible studies of moderate quality (11,034 participants) including 51 biomarkers at varying thresholds for diagnosing bacterial infections. An elevated Procalcitonin (≥ 0.2 ng/mL) may help diagnose bacteraemia in older adults [+ve LR range 1.50 to 2.60]. A CRP ≥ 50 mg/L only raises the probability of bacteraemia by 5%. A positive urine dipstick aids diagnosis of UTI (+ve LR range 1.23 to 54.90), and absence helps rule out UTI (−ve LR range 0.06 to 0.46). An elevated white blood cell count is unhelpful in diagnosing intra-abdominal infections (+ve LR range 0.75 to 2.62), but may aid differentiation of bacterial infection from other acute illness (+ve LR range 2.14 to 7.12). Conclusions The limited available evidence suggests that many diagnostic tests useful in younger patients, do not help to diagnose bacterial infections in older adults. Further evidence from high quality studies is urgently needed to guide clinical practice. Until then, symptoms and signs remain the mainstay of diagnosis in community based populations. Electronic supplementary material The online version of this article (10.1186/s12877-019-1205-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Oghenekome A Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Igho J Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Georgia C Richards
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Elizabeth A Spencer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Niklas Bobrovitz
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Carl J Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Holtman GA, Berger MY, Burger H, Deeks JJ, Donner-Banzhoff N, Fanshawe TR, Koshiaris C, Leeflang MM, Oke JL, Perera R, Reitsma JB, Van den Bruel A. Development of practical recommendations for diagnostic accuracy studies in low-prevalence situations. J Clin Epidemiol 2019; 114:38-48. [PMID: 31150837 DOI: 10.1016/j.jclinepi.2019.05.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 07/19/2018] [Revised: 04/04/2019] [Accepted: 05/22/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Low disease prevalence poses challenges for diagnostic accuracy studies because of the large sample sizes that are required to obtain sufficient precision. The aim is to collate and discuss designs of diagnostic accuracy studies suited for use in low-prevalence situations. STUDY DESIGN AND SETTING We conducted a literature search including backward citation tracking and expert consultation. Two reviewers independently selected studies on designs for estimating diagnostic accuracy in a low-prevalence situation. During a 1-day expert meeting, all designs were discussed and recommendations were formulated. RESULTS We identified six designs for diagnostic accuracy studies that are suitable in low-prevalence situations because they reduced the total sample size or the number of patients undergoing the index test or reference standard depending on which poses the highest burden. We described the advantages and limitations of these designs and evaluated efficiencies in sample sizes, risk of bias, and alignment with the clinical pathway for applicability in routine care. CONCLUSION Choosing a study design for diagnostic accuracy studies in low-prevalence situations should depend on whether the aim is to limit the number of patients undergoing the index test or reference standard, and the risk of bias associated with a particular design type.
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Affiliation(s)
- Gea A Holtman
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford OX2 6GG, UK; Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, PO Box 196, 9700 AD Groningen, the Netherlands.
| | - Marjolein Y Berger
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, PO Box 196, 9700 AD Groningen, the Netherlands
| | - Huibert Burger
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, PO Box 196, 9700 AD Groningen, the Netherlands
| | - Jonathan J Deeks
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham B15 2TT, UK
| | - Norbert Donner-Banzhoff
- Department of General Practice and Family Medicine, Faculty of Medicine, Philipps University of Marburg, Karl-von-Str. 4, Marburg 35037, Germany
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford OX2 6GG, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford OX2 6GG, UK
| | - Mariska M Leeflang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, the Netherlands
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford OX2 6GG, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford OX2 6GG, UK
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford OX2 6GG, UK; Academic Centre of General Practice, University of Leuven, Kapucijnenvoer 33 blok J, Bus 7001, 3000 Leuven, Belgium
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Nicholson BD, Aveyard P, Hamilton W, Bankhead CR, Koshiaris C, Stevens S, Hobbs FD, Perera R. The internal validation of weight and weight change coding using weight measurement data within the UK primary care Electronic Health Record. Clin Epidemiol 2019; 11:145-155. [PMID: 30774449 PMCID: PMC6354686 DOI: 10.2147/clep.s189989] [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] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To use recorded weight values to internally validate weight status and weight change coding in the primary care Electronic Health Record (EHR). PATIENTS AND METHODS We included adult patients with weight-related Read codes recorded in the UK's Clinical Practice Research Datalink EHR between 2000 and 2017. Weight status codes were compared to weight values recorded on the same day and positive predictive values (PPVs) were calculated for commonly used codes. Weight change codes were validated using three methods: the percentage (%) difference in kilograms at the time of the code and 1) the previous weight measurement, 2) the weight predicted using linear regression, and 3) the historic mean weight. Weight change codes were validated if estimates were consistent across two out of three methods. RESULTS A total of 8,108,481 weight codes were recorded in 1,000,002 patients' EHR. Twice as many were recorded in females (n=5,208,593, 64%). The mean body mass index for "overweight" codes ranged from 31.9 kg/m2 to 46.9 kg/m2 and from 17.4 kg/m2 to 19.2 kg/m2 for "underweight" codes. PPVs for the most commonly used weight status codes ranged from 81.3% (80%-82.5%) to 99.3% (99.2%-99.4%). Across the estimation methods, and using only validated weight change codes, mean weight loss ranged from - 5.2% (SD 5.8%) to -7.9% (SD 7.3%) and mean weight gain from 4.2 % (SD 5.5%) to 7.9 % (SD 8.2%). The previous and predicted weight methods were most consistent. CONCLUSION We have developed an internationally applicable methodology to internally validate weight-related EHR coding by using available weight measurement data. We demonstrate the UK Read codes that can be confidently used to classify weight status and weight change in the absence of weight values. We provide the first evidence from primary care that a Read code for unexpected weight loss represents a mean loss of ≥ 5 % in a 6-month period, which was broadly consistent across age groups and gender.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX26GG, UK,
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX26GG, UK,
| | - Willie Hamilton
- College of Medicine and Health, University of Exeter, Exeter EX1 2LU, UK
| | - Clare R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX26GG, UK,
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX26GG, UK,
| | - Sarah Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX26GG, UK,
| | - Frederick Dr Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX26GG, UK,
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX26GG, UK,
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Hartmann-Boyce J, Aveyard P, Piernas C, Koshiaris C, Velardo C, Salvi D, Jebb SA. Cognitive and behavioural strategies for weight management in overweight adults: Results from the Oxford Food and Activity Behaviours (OxFAB) cohort study. PLoS One 2018; 13:e0202072. [PMID: 30096203 PMCID: PMC6086460 DOI: 10.1371/journal.pone.0202072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 04/18/2017] [Accepted: 07/29/2018] [Indexed: 11/29/2022] Open
Abstract
Background Though many overweight and obese adults attempt to lose weight without formal support, little is known about the strategies used in self-directed weight loss attempts. We set out to assess cognitive and behavioural strategies for weight loss and their associations with weight change. Methods Prospective, web-based cohort study of overweight UK adults (BMI≥25kg/m2) trying to lose weight through behaviour change. Strategy use was assessed using the OxFAB questionnaire and evaluated (1) at the domain level, (2) through exploratory factor analysis, and (3) in a model of strategies deemed a priori to be “essential” to weight management. Associations with weight change at 3 months were tested using linear regression. Results 486 participants answered all questions; 194 reported weight at baseline and at 3 months (mean weight change -3.3kg (SD 4.1)). Greater weight loss was significantly associated with the motivational support domain (-2.4kg, 95% CI -4.4 to -0.4), dietary impulse control (from factor analysis) (-0.6kg, 95% CI -1.1 to -0.03), and weight loss planning and monitoring (from factor analysis) (-1.3kg, 95% CI -2.0 to -0.5). Higher scores in the model of essential behavioural strategies were significantly associated with greater weight loss (compared to participants using 6 or fewer of the 9 strategies, using 7 or more of the 9 strategies was associated with a 2.13kg greater weight loss (SE 0.58, p<0.001)). Conclusions Despite heterogeneity in the strategies employed for weight loss, coherent patterns of behaviours emerged for individual participants, some of which were associated with greater weight loss, including strategies relating to dietary impulse control, weight loss planning and monitoring, motivational support, information seeking and self-monitoring. Trials could test the effect of promoting use of these patterns on weight loss.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Oxford, United Kingdom
- * E-mail:
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Carmen Piernas
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Carmelo Velardo
- Institute of Biomedical Engineering, Department of Engineering Sciences, Old Road Campus Research Building, University of Oxford, Headington, Oxford, United Kingdom
| | - Dario Salvi
- Institute of Biomedical Engineering, Department of Engineering Sciences, Old Road Campus Research Building, University of Oxford, Headington, Oxford, United Kingdom
| | - Susan A. Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Oxford, United Kingdom
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Abstract
OBJECTIVES To quantify the duration of each step of the diagnostic pathway for patients with multiple myeloma from symptom onset to confirmation of diagnosis. DESIGN Systematic review and meta-analysis. DATA SOURCES AND SELECTION CRITERIA The MEDLINE and Embase databases were searched up until January 2018 to identify articles that reported time intervals from onset of symptoms to diagnosis. Articles focusing on children or adolescents and on the asymptomatic form of the disease (monoclonal gammopathies and smouldering myeloma) were excluded. DATA COLLECTION AND DATA ANALYSIS Data were extracted independently by two reviewers. Weighted estimates of the median and IQR were calculated. Risk of bias was assessed using the Aarhus checklist. MAIN RESULTS Nine studies were included. The patient interval (first symptom to first presentation) had a median of 26.3 days (IQR: 1-98, n=465, two studies). Subsequently, the primary care interval (first presentation to first referral) was 21.6 days (IQR: 4.6-55.8, n=326, two studies), the diagnostic interval (first presentation to diagnosis) was 108.6 days (IQR: 33.3-241.7, n=5395, seven studies) and the time to diagnosis (first symptom to diagnosis) interval was 163 days (IQR: 84-306, n=341, one study). No studies reported data for the referral to diagnosis interval. CONCLUSION The review demonstrates that there is scope for significant reductions in the time to myeloma diagnosis. At present, many patients experience a diagnostic interval longer than 3 months until diagnosis is confirmed. REVIEW REGISTRATION Not available. Protocol available in the appendix.
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Affiliation(s)
| | - Jason Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karthik Ramasamy
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, UK
- National Institute for Health Research (NIHR) Biomedical Research Center Blood Theme, Oxford, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Lee JJ, Thompson MJ, Usher-Smith JA, Koshiaris C, Van den Bruel A. Opportunities for earlier diagnosis of type 1 diabetes in children: A case-control study using routinely collected primary care records. Prim Care Diabetes 2018; 12:254-264. [PMID: 29548694 DOI: 10.1016/j.pcd.2018.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/18/2018] [Accepted: 02/03/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND The epidemiology of type 1 diabetes mellitus (T1DM) suggests diagnostic delays may contribute to children developing diabetic ketoacidosis at diagnosis. We sought to quantify opportunities for earlier diagnosis of T1DM in primary care. METHODS A matched case-control study of children (0-16 years) presenting to UK primary care, examining routinely collected primary care consultation types and National Institute for Health and Care Excellence (NICE) warning signs in the 13 weeks before diagnosis. RESULTS Our primary analysis included 1920 new T1DM cases and 7680 controls. In the week prior to diagnosis more cases than controls had medical record entries (663, 34.5% vs 1014, 13.6%, odds ratio 3.46, 95% CI 3.07-3.89; p<0.0001) and the incidence rate of face-to-face consultations was higher in cases (mean 0.32 vs 0.11, incidence rate ratio 2.90, 2.61-3.21; p<0.0001). The preceding week entries were found in 330 cases and 943 controls (17.2% vs 12.3%, OR 1.49, 1.3-1.7, p<0.0001), but face-to-face consultations were no different (IRR 1.08 (0.9-1.29, p=0.42)). INTERPRETATION There may be opportunities to reduce time to diagnosis for up to one third of cases, by up to two weeks. Diagnostic opportunities might be maximised by measures that improve access to primary care, and public awareness of T1DM.
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Affiliation(s)
- Joseph Jonathan Lee
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK.
| | - Matthew James Thompson
- Department of Family Medicine, University of Washington, Box 354696, Seattle, WA 89195-4596, USA.
| | - Juliet Alexandra Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Box 113 Cambridge Biomedical Campus, Cambridge CB2 0SR, UK.
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK.
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK.
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Vergunst F, Rugkåsa J, Koshiaris C, Simon J, Burns T. Community treatment orders and social outcomes for patients with psychosis: a 48-month follow-up study. Soc Psychiatry Psychiatr Epidemiol 2017; 52:1375-1384. [PMID: 28900690 DOI: 10.1007/s00127-017-1442-5] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 08/31/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Community treatment orders (CTOs) are widely used internationally despite a lack of evidence supporting their effectiveness. Most effectiveness studies are relatively short (12-months or less) and focus on clinical symptoms and service data, while a little attention is given to patients' social outcomes and broader welfare. We tested the association between the duration of CTO intervention and patients' long-term social outcomes. METHODS A sub-sample (n = 114) of community-based patients from the Oxford Community Treatment Order Evaluation Trial (OCTET) were interviewed 48 months after randomisation. Multivariate regression models were used to examine the association between the duration of the CTO intervention and social outcomes as measured by the social network schedule, Objective Social Outcomes Index, Euro-Qol EQ-5D-3L (EQ-5D), and Oxford Capabilities Questionnaire for Mental Health. RESULTS No significant association was found between the duration of CTO intervention and social network size (IRR = 0.996, p = .63), objective social outcomes (B = -0.003, p = .77), health-related quality of life (B = 0.001, p = .77), and capabilities (B = 0.046, p = .41). There were no between-group differences in social outcomes when outcomes were stratified by original arm of randomisation. Patients had a mean of 10.2 (SD = 5.9) contacts in their social networks, 42% of whom were relatives. CONCLUSIONS CTO duration was not associated with improvements in patients' social outcomes even over the long term. This study adds to growing concerns about CTO effectiveness and the justification for their continued use.
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Affiliation(s)
- Francis Vergunst
- Research Unit On Children's Psychosocial Maladjustment, University of Montreal, 3175 Chemin de la Côte Ste-Catherine, Montreal, H3T 1C5, Canada. .,Department of Psychiatry, University of Oxford, Oxford, UK.
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Centre for Care Research, University College of Southeast Norway, Notodden, Norway
| | | | - Judit Simon
- Department of Health Economics, Centre for Public Health, Medical University of Vienna, Vienna, Austria.,Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tom Burns
- Department of Psychiatry, University of Oxford, Oxford, UK
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Koshiaris C, Aveyard P, Oke J, Ryan R, Szatkowski L, Stevens R, Farley A. Smoking cessation and survival in lung, upper aero-digestive tract and bladder cancer: cohort study. Br J Cancer 2017; 117:1224-1232. [PMID: 28898236 PMCID: PMC5674091 DOI: 10.1038/bjc.2017.179] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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: 01/23/2017] [Revised: 04/26/2017] [Accepted: 05/26/2017] [Indexed: 12/19/2022] Open
Abstract
Background: The aim was to examine the association between smoking cessation and prognosis in smoking-related cancer as it is unclear that cessation reduces mortality. Methods: In this retrospective cohort study from 1999 to 2013, we assessed the association between cessation during the first year after diagnosis and all-cause and cancer-specific mortality. Results: Of 2882 lung, 757 upper aero-digestive tract (UAT) and 1733 bladder cancer patients 27%, 29% and 21% of lung, UAT and bladder cancer patients quit smoking. In lung cancer patients that quit, all-cause mortality was significantly lower (HR: 0.82 (0.74–0.92), while cancer-specific mortality (HR: 0.89 (0.76–1.04) and death due to index cancer (HR: 0.90 (0.77–1.05) were non-significantly lower. In UAT cancer, all-cause mortality (HR: 0.81 (0.58–1.14), cancer-specific mortality (HR: 0.84 (0.48–1.45), and death due to index cancer (HR: 0.75 (0.42–1.34) were non-significantly lower. There was no evidence of an association between quitting and mortality in bladder cancer. The HRs were 1.02 (0.81–1.30) for all-cause, 1.23 (0.81–1.86) for cancer specific, and 1.25 (0.71–2.20) for death due to index cancer. These showed a non-significantly lower risk in sensitivity analyses. Conclusions: People with lung and possibly UAT cancer who quit smoking have a lower risk of mortality than people who continue smoking.
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Affiliation(s)
- C Koshiaris
- Nuffield Department of Primary Care Health Sciences, UK Centre for Tobacco and Alcohol Studies, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - P Aveyard
- Nuffield Department of Primary Care Health Sciences, UK Centre for Tobacco and Alcohol Studies, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - J Oke
- Nuffield Department of Primary Care Health Sciences, UK Centre for Tobacco and Alcohol Studies, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - R Ryan
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - L Szatkowski
- Division of Epidemiology and Public Health, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham NG5 1PB, UK
| | - R Stevens
- Nuffield Department of Primary Care Health Sciences, UK Centre for Tobacco and Alcohol Studies, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - A Farley
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Farley A, Koshiaris C, Oke J, Ryan R, Szatkowski L, Stevens R, Aveyard P. Physician Support of Smoking Cessation After Diagnosis of Lung, Bladder, or Upper Aerodigestive Tract Cancer. Ann Fam Med 2017; 15:443-450. [PMID: 28893814 PMCID: PMC5593727 DOI: 10.1370/afm.2100] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/27/2017] [Accepted: 02/19/2017] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Smoking cessation after a diagnosis of lung, bladder, and upper aerodigestive tract cancer appears to improve survival, and support to quit would improve cessation. The aims of this study were to assess how often general practitioners provide active smoking cessation support for these patients and whether physician behavior is influenced by incentive payments. METHODS Using electronic primary care records from the UK Clinical Practice Research Datalink, 12,393 patients with incident cases of cancer diagnosed between 1999 and 2013 were matched 1 to 1 to patients with incident cases of coronary heart disease (CHD) diagnosed during the same time. We assessed differences in the proportion for whom physicians updated smoking status, advised quitting, and prescribed cessation medications, as well as the proportion of patients who stopped smoking within a year of diagnosis. We further examined whether any differences arose because the physicians were offered incentives to address smoking in patients with CHD and not cancer. RESULTS At diagnosis, 32.0% of patients with cancer and 18.2% of patients with CHD smoked tobacco. Patients with cancer were less likely than patients with CHD to have their general practitioners update smoking status (OR = 0.18; 95% CI, 0.17-0.19), advise quitting (OR = 0.38; 95% CI, 0.36-0.40), or prescribe medication (OR = 0.67; 95% CI, 0.63-0.73), and they were less likely to have stopped smoking (OR = 0.76; 95% CI, 0.69-0.84). One year later 61.7% of patients with cancer and 55.4% with CHD who were smoking at diagnosis were still smoking. Introducing incentive payments was associated with more frequent interventions, but not for patients with CHD specifically. CONCLUSIONS General practitioners were less likely to support smoking cessation in patients with cancer than with CHD, and patients with cancer were less likely to stop smoking. This finding is not due to the difference in incentive payments.
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Affiliation(s)
- Amanda Farley
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, UK Centre for Tobacco and Alcohol Studies, University of Oxford, Oxford, United Kingdom
| | - Jason Oke
- Nuffield Department of Primary Care Health Sciences, UK Centre for Tobacco and Alcohol Studies, University of Oxford, Oxford, United Kingdom
| | - Ronan Ryan
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Lisa Szatkowski
- Division of Epidemiology and Public Health, UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, United Kingdom
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, UK Centre for Tobacco and Alcohol Studies, University of Oxford, Oxford, United Kingdom
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, UK Centre for Tobacco and Alcohol Studies, University of Oxford, Oxford, United Kingdom
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Schwartz CL, Clark C, Koshiaris C, Gill PS, Greenfield SM, Haque SM, Heer G, Johal A, Kaur R, Mant J, Martin U, Mohammed MA, Wood S, McManus RJ. Interarm Difference in Systolic Blood Pressure in Different Ethnic Groups and Relationship to the "White Coat Effect": A Cross-Sectional Study. Am J Hypertens 2017; 30:884-891. [PMID: 28475667 PMCID: PMC5861584 DOI: 10.1093/ajh/hpx073] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 04/05/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Interarm differences (IADs) ≥10 mm Hg in systolic blood pressure (BP) are associated with greater incidence of cardiovascular disease. The effect of ethnicity and the white coat effect (WCE) on significant systolic IADs (ssIADs) are not well understood. METHODS Differences in BP by ethnicity for different methods of BP measurement were examined in 770 people (300 White British, 241 South Asian, 229 African-Caribbean). Repeated clinic measurements were obtained simultaneously in the right and left arm using 2 BPTru monitors and comparisons made between the first reading, mean of second and third and mean of second to sixth readings for patients with, and without known hypertension. All patients had ambulatory BP monitoring (ABPM). WCE was defined as systolic clinic BP ≥10 mm Hg higher than daytime ABPM. RESULTS No significant differences were seen in the prevalence of ssIAD between ethnicities whichever combinations of BP measurement were used and regardless of hypertensive status. ssIADs fell between the 1st measurement (161, 22%), 2nd/3rd (113, 16%), and 2nd–6th (78, 11%) (1st vs. 2nd/3rd and 2nd–6th, P < 0.001). Hypertensives with a WCE were more likely to have ssIADs on 1st, (odds ratio [OR] 1.73 (95% confidence interval 1.04–2.86); 2nd/3rd, (OR 3.05 (1.68–5.53); and 2nd–6th measurements, (OR 2.58 (1.22–5.44). Nonhypertensive participants with a WCE were more likely to have a ssIAD on their first measurement (OR 3.82 (1.77 to −8.25) only. CONCLUSIONS ssIAD prevalence does not vary with ethnicity regardless of hypertensive status but is affected by the number of readings, suggesting the influence of WCE. Multiple readings should be used to confirm ssIADs.
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Affiliation(s)
- Claire Lorraine Schwartz
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Christopher Clark
- Primary Care Research Group, University of Exeter Medical School, Smeall Building, St Luke’s Campus, Exeter, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Paramjit S Gill
- WMS—Social Science and Systems in Health, University of Warwick, Coventry, Birmingham, UK
| | - Shelia M Greenfield
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Sayeed M Haque
- Institute of Clinical Science, University of Birmingham, Edgbaston, Birmingham, UK
| | - Gurdip Heer
- Institute of Clinical Science, University of Birmingham, Edgbaston, Birmingham, UK
| | - Amanpreet Johal
- NIHR Clinical Research Network: West Midlands, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ramandeep Kaur
- Institute of Clinical Science, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Wort’s Causeway, Cambridge, Cambridgeshire, UK
| | - Una Martin
- Institute of Clinical Science, University of Birmingham, Edgbaston, Birmingham, UK
| | | | - Sally Wood
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
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Collins D, Lee J, Bobrovitz N, Koshiaris C, Ward A, Heneghan C. whoishRisk - an R package to calculate WHO/ISH cardiovascular risk scores for all epidemiological subregions of the world. F1000Res 2016; 5:2522. [PMID: 28357040 PMCID: PMC5345772 DOI: 10.12688/f1000research.9742.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2017] [Indexed: 02/03/2023] Open
Abstract
The World Health Organisation and International Society of Hypertension (WHO/ISH) cardiovascular disease (CVD) risk assessment charts have been implemented in many low- and middle-income countries as part of the WHO Package of Essential Non-Communicable Disease (PEN) Interventions for Primary Health Care in Low-Resource settings. Evaluation of the WHO/ISH cardiovascular risk charts and their use is a key priority and since they only existed in paper or PDF formats, we developed an R implementation of the charts for all epidemiological subregions of the world. The main strengths of this implementation are that it is built in a free, open-source, coding language with simple syntax, can be downloaded from github as a package (“whoishRisk”), and can be used with a standard computer.
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Affiliation(s)
- Dylan Collins
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joseph Lee
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Niklas Bobrovitz
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Alison Ward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Abstract
OBJECTIVE To systematically review studies quantifying the associations of long term (clinic), mid-term (home), and short term (ambulatory) variability in blood pressure, independent of mean blood pressure, with cardiovascular disease events and mortality. DATA SOURCES Medline, Embase, Cinahl, and Web of Science, searched to 15 February 2016 for full text articles in English. ELIGIBILITY CRITERIA FOR STUDY SELECTION Prospective cohort studies or clinical trials in adults, except those in patients receiving haemodialysis, where the condition may directly impact blood pressure variability. Standardised hazard ratios were extracted and, if there was little risk of confounding, combined using random effects meta-analysis in main analyses. Outcomes included all cause and cardiovascular disease mortality and cardiovascular disease events. Measures of variability included standard deviation, coefficient of variation, variation independent of mean, and average real variability, but not night dipping or day-night variation. RESULTS 41 papers representing 19 observational cohort studies and 17 clinical trial cohorts, comprising 46 separate analyses were identified. Long term variability in blood pressure was studied in 24 papers, mid-term in four, and short-term in 15 (two studied both long term and short term variability). Results from 23 analyses were excluded from main analyses owing to high risks of confounding. Increased long term variability in systolic blood pressure was associated with risk of all cause mortality (hazard ratio 1.15, 95% confidence interval 1.09 to 1.22), cardiovascular disease mortality (1.18, 1.09 to 1.28), cardiovascular disease events (1.18, 1.07 to 1.30), coronary heart disease (1.10, 1.04 to 1.16), and stroke (1.15, 1.04 to 1.27). Increased mid-term and short term variability in daytime systolic blood pressure were also associated with all cause mortality (1.15, 1.06 to 1.26 and 1.10, 1.04 to 1.16, respectively). CONCLUSIONS Long term variability in blood pressure is associated with cardiovascular and mortality outcomes, over and above the effect of mean blood pressure. Associations are similar in magnitude to those of cholesterol measures with cardiovascular disease. Limited data for mid-term and short term variability showed similar associations. Future work should focus on the clinical implications of assessment of variability in blood pressure and avoid the common confounding pitfalls observed to date. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014015695.
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Affiliation(s)
- Sarah L Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Sally Wood
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Kathryn Law
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Paul Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| | - Richard J Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
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Hartmann‐Boyce J, Aveyard P, Koshiaris C, Jebb SA. Development of tools to study personal weight control strategies: OxFAB taxonomy. Obesity (Silver Spring) 2016; 24:314-20. [PMID: 26748902 PMCID: PMC4744943 DOI: 10.1002/oby.21341] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 08/21/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe the development of the Oxford Food and Activity Behaviors (OxFAB) taxonomy and questionnaire to explore the cognitive and behavioral strategies used by individuals during weight management attempts. METHODS The taxonomy was constructed through a qualitative analysis of existing resources and a review of existing behavior change taxonomies and theories. The taxonomy was translated into a questionnaire to identify strategies used by individuals. Think-aloud interviews were conducted to test the face/concept validity of the questionnaire, and test-retest reliability was assessed in a sample of 138 participants. RESULTS The OxFAB taxonomy consists of 117 strategies grouped into 23 domains. Compared to taxonomies used to describe interventions, around half of the domains and strategies identified are unique to the OxFAB taxonomy. The OxFAB questionnaire consists of 117 questions, one for each strategy from the taxonomy. Test-retest resulted in a mean PABAK score of 0.61 (SD 0.15). Questions were revised where appropriate. CONCLUSIONS The OxFAB taxonomy and questionnaire provide a conceptual framework to identify the cognitive and behavioral strategies used by individuals during attempts at weight control.
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Affiliation(s)
| | - Paul Aveyard
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | | | - Susan A. Jebb
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
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Gonçalves-Bradley DC, Boylan AM, Koshiaris C, Vazquez Montes M, Ford GA, Lasserson DS. GPs' adherence to guidelines for structured assessments of stroke survivors in the community and care homes. Fam Pract 2015; 32:659-63. [PMID: 26424724 PMCID: PMC5926456 DOI: 10.1093/fampra/cmv074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Clinical practice guidelines recommend that stroke survivors' needs be assessed at regular intervals after stroke. The extent to which GPs comply with national guidance particularly for patients in care homes who have greatest clinical complexity is unknown. OBJECTIVES This study aimed to establish the current clinical practice in the UK of needs assessment by GPs for stroke survivors after hospital discharge for acute stroke. METHODS Cross-sectional online survey of current practice of GPs, using the national doctors.net network. RESULTS The survey was completed by 300 GPs who had on average been working for 14 years. The structured assessment of stroke survivors' needs was not offered by 31% of GPs, with no significant difference for level of provision in community or care home settings. The outputs of reviews were added to patients' notes by 89% of GPs and used to change management by 57%. Only half the GPs reported integrating the information obtained into care plans and only a quarter of GPs had a protocol for follow-up of identified needs. Analysis of free-text comments indicated that patients in some care homes may receive more regular and structured reviews. CONCLUSIONS This survey suggests that at least one-third of GPs provide no formal review of the needs of stroke patients and that in only a minority are identified needs addressed in a structured way. Standardization is required for what is included in reviews and how needs are being identified and met.
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Affiliation(s)
- Daniela C Gonçalves-Bradley
- Nuffield Department of Population Health, University of Oxford Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Walton Street, Oxford OX2 6GG
| | - Anne-Marie Boylan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Walton Street, Oxford OX2 6GG
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Walton Street, Oxford OX2 6GG
| | - Maria Vazquez Montes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Walton Street, Oxford OX2 6GG
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, Level 3, John Radcliffe Hospital, Oxford OX3 9DU and
| | - Daniel S Lasserson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Walton Street, Oxford OX2 6GG, Medical Sciences Division, University of Oxford, Level 3, John Radcliffe Hospital, Oxford OX3 9DU and NIHR Oxford Biomedical Research Centre, The Joint Research Office, Block 60, The Churchill Hospital, Old Road, Headington OX3 7LE, UK.
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Burns T, Yeeles K, Koshiaris C, Vazquez-Montes M, Molodynski A, Puntis S, Vergunst F, Forrest A, Mitchell A, Burns K, Rugkåsa J. Effect of increased compulsion on readmission to hospital or disengagement from community services for patients with psychosis: follow-up of a cohort from the OCTET trial. Lancet Psychiatry 2015; 2:881-90. [PMID: 26362496 DOI: 10.1016/s2215-0366(15)00231-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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] [Received: 02/20/2015] [Revised: 04/11/2015] [Accepted: 05/08/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Community treatment orders (CTOs) have not been shown in randomised trials to reduce readmission to hospital in patients with psychosis, but these trials have been short (11-12 months). We previously investigated the effect of CTOs on readmission rates over 12 months in a randomised trial (OCTET). Here, we present follow-up data for a cohort of individuals recruited to our original trial to examine the long-term effect of CTOs on readmissions and the risk of patients disengaging from mental health services temporarily or enduringly. METHODS For OCTET, an open-label, parallel, randomised controlled trial, we recruited patients aged 18-65 years involuntarily admitted to mental health hospitals in 32 trusts in England, with a diagnosis of psychosis and deemed suitable for CTOs by their clinicians. Between Nov 10, 2008, and Feb 22, 2011, we recruited and randomly assigned 336 eligible patients (1:1) to be discharged on either a CTO (n=167) or to voluntary status via Section 17 leave (control group; n=169). For the analysis presented in this report, we assessed data at 36 months for 330 of these patients. We tested rates of readmission to hospital, time to first readmission, number of readmissions, and duration of readmission in patients assigned to CTO versus those assigned to control, and in all patients with CTO experience at any time in the 36 months versus those without. We also tested whether duration of CTO affected readmission outcomes in patients with CTO experience. We examined discontinuation (≥60 days between clinical contacts) and disengagement from services (no clinical contact for ≥90 days with no return to contact) in the whole cohort. OCTET is registered with isrctn.com, number ISRCTN73110773. FINDINGS We obtained data for 330 patients in the relevant period between Nov 10, 2008 and Feb 22, 2014 (36 months after the last patient was randomly assigned to OCTET). We identified no difference between the randomised groups in the numbers of patients readmitted (100 [61%] of 165 CTOs vs 113 [68%] of 165 controls; relative risk 0·88 [95% CI 0·75-1·03]), number of readmissions (mean 2·4 readmissions [SD 1·91] vs 2·2 [1·43]; incident density ratio [IDR] 0·97 [95% CI 0·76-1·24]), duration of readmissions (median 117·5 days [IQR 63-303] vs 139·5 days [63·0-309·5]; IDR 0·84 [95% CI 0·51-1·38]), or time to first readmission (median 601·0 days [95% CI 387·0-777·0] vs 420·0 days [352·0-548·0]; hazard ratio [HR] 0·81 [95% CI 0·62-1·06]). The CTO experience group had significantly more readmissions than the group without (IDR 1·39 [95% CI 1·07-1·79]) and we noted no significant difference between groups in readmission rates, duration of readmission, or time to first readmission. We did not identify a linear relationship between readmission outcomes and duration of CTO. 19 (6%) patients disengaged from services (12 [7%] of 165 CTOs vs 7 [4%] of 165 controls). Longer duration of compulsion was associated with later disengagement (HR 0·946 [95% CI 0·90-0·99, p=0·023). 187 (57%) experienced no discontinuities, and we noted no significant difference between the CTO and control groups for time to disengagement or number of discontinuities. Levels of discontinuity were associated with compulsion (IDR 0·973 [95% CI 0·96-0·99, p<0·0001]. We identified no effect of baseline characteristics on the associations between compulsion and disengagement. INTERPRETATION We identified no evidence that increased compulsion leads to improved readmission outcomes or to disengagement from services in patients with psychosis over 36 months. The level of persisting clinical follow-up was much higher than expected, irrespective of CTO status, and could partly account for the absence of CTO effect. The findings from our 36-month follow-up support our original findings that CTOs do not provide patient benefits, and the continued high level of their use should be reviewed. FUNDING National Institute for Health Research.
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Affiliation(s)
- Tom Burns
- Department of Psychiatry, University of Oxford, Oxford, UK.
| | - Ksenija Yeeles
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | - Maria Vazquez-Montes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK; National Institute for Health Research, Oxford Biomedical Research Centre Research Fellow, The Churchill Hospital, Oxford, UK
| | | | - Stephen Puntis
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | - Alexandra Forrest
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Amy Mitchell
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Kiki Burns
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Jorun Rugkåsa
- Department of Psychiatry, University of Oxford, Oxford, UK; Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
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