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Pinto CA, Tervonen T, Jimenez-Moreno C, Levitan B, Soriano Gabarró M, Girman C, Norquist JM, Hauber B. Current Practices and Challenges When Submitting Patient Experience Data for Regulatory Decisions by the US Food and Drug Administration: An Industry Survey. Patient 2024; 17:147-159. [PMID: 38085458 PMCID: PMC10894141 DOI: 10.1007/s40271-023-00653-8] [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] [Subscribe] [Scholar Register] [Accepted: 10/08/2023] [Indexed: 02/25/2024]
Abstract
OBJECTIVES To understand industry practices and challenges when submitting patient experience data (PED) for regulatory decisions by the US Food and Drug Administration (FDA). METHODS A two-part online survey related to collection, submission, and use of PED by FDA in regulatory decision-making (part 1) and a best-worst exercise for prioritizing potential PED initiatives (part 2) was completed by industry and contract research organization (CRO) members with ≥ 2 years of recent experience with patient-reported outcome (PRO), natural history study (NHS), or patient preference (PP) data; and direct experience with FDA filings including PED. RESULTS A total of 50 eligible respondents (84% industry) completed part 1 of the survey, among which 46 completed part 2. Respondents mostly had PRO (86%) and PP (50%) experience. All indicated that FDA meetings should have a standing agenda item to discuss PED. Most (78%) reported meetings should occur before pivotal trials. A common challenge was justifying inclusion without knowing if and how data will be used. Most agreed that FDA and industry should co-develop the PED table in the FDA clinical review (74%), and the table should report reason(s) for not using PED (96%) in regulatory decision-making. Most important efforts to advance PED use in decision-making were a dedicated meeting pathway and expanded FDA guidance (51% each). CONCLUSIONS FDA has policy targets expanding PED use, but challenges remain regarding pathways for PED submission and transparency in regulatory decision-making. Alignment on the use of existing meeting opportunities to discuss PED, co-development of the PED table, and expanded guidance are encouraged.
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Affiliation(s)
| | | | | | | | | | | | | | - Brett Hauber
- Pfizer, New York, NY, USA
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle, WA, USA
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2
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Webster-Clark M, Mavros P, Garry EM, Stürmer T, Shmuel S, Young J, Girman C. Alternative analytic and matching approaches for the prevalent new-user design: A simulation study. Pharmacoepidemiol Drug Saf 2022; 31:796-803. [PMID: 35505471 DOI: 10.1002/pds.5446] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe the creation of prevalent new user (PNU) cohorts and compare the relative bias and computational efficiency of several alternative analytic and matching approaches in PNU studies. METHODS In a simulated cohort, we estimated the effect of a treatment of interest vs a comparator among those who switched to the treatment of interest using the originally proposed time-conditional propensity score (TCPS) matching, standardized morbidity ratio weighting (SMRW), disease risk scores (DRS), and several alternative propensity score matching approaches. For each analytic method, we compared the average RR (across 2000 replicates) to the known risk ratio (RR) of 1.00. RESULTS SMRW and DRS yielded unbiased results (RR = 0.998 and 0.997, respectively). TCPS matching with replacement was also unbiased (RR = 0.999). TCPS matching without replacement was unbiased when matches were identified starting with patients with the shortest treatment history as initially proposed (RR = 0.999), but it resulted in very slight bias (RR = 0.983) when starting with patients with the longest treatment history. Similarly, creating a match pool without replacement starting with patients with the shortest treatment history yielded an unbiased estimate (RR = 0.997), but matching with the longest treatment history first resulted in substantial bias (RR = 0.903). The most biased strategy was matching after selecting one random comparator observation per individual that continued on the comparator (RR = 0.802). CONCLUSIONS Multiple analytic methods can estimate treatment effects without bias in a PNU cohort. Still, researchers should be wary of introducing bias when selecting controls for complex matching strategies beyond the initially proposed TCPS.
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Affiliation(s)
- Michael Webster-Clark
- Department of Epidemiology, Gillings Schools of Global Public Health, UNC Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | - Panagiotis Mavros
- Janssen Scientific Affairs LLC, the Janssen Pharmaceutical Companies of J&J, Titusville, New Jersey, USA.,KREDHERA, LLC, Hampton, New Jersey, USA
| | | | - Til Stürmer
- Department of Epidemiology, Gillings Schools of Global Public Health, UNC Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shahar Shmuel
- Cecil G Sheps Center for Health Services Research, UNC Chapel Hill, Chapel Hill, North Carolina, USA.,CERobs Consulting, LLC, Wrightsville Beach, North Carolina, USA
| | - Jessica Young
- Department of Epidemiology, Gillings Schools of Global Public Health, UNC Chapel Hill, Chapel Hill, North Carolina, USA.,CERobs Consulting, LLC, Wrightsville Beach, North Carolina, USA
| | - Cynthia Girman
- CERobs Consulting, LLC, Wrightsville Beach, North Carolina, USA
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3
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Girman C, Panaccio MP, Hayes K, Niewoehner J, Wan GJ. Pain and Fatigue Improvements in Patients Treated with Repository Corticotropin Injection Across Five Indications: A Narrative Review. Adv Ther 2022; 39:3072-3087. [PMID: 35635646 PMCID: PMC9239937 DOI: 10.1007/s12325-022-02176-4] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/29/2022] [Indexed: 11/28/2022]
Abstract
Repository corticotropin injection (RCI; Acthar® Gel) is approved by the US Food and Drug Administration (FDA) for use in 19 indications, including for the treatment of selected patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), symptomatic sarcoidosis, uveitis, and keratitis. Despite treatment with disease-modifying antirheumatic drugs, many patients with RA, SLE, and other chronic inflammatory rheumatic diseases continue to be affected by severe pain and fatigue, indicating a need for other therapies. To examine the clinical data regarding the impact of RCI treatment on pain and fatigue in selected populations, this review included English-language peer-reviewed publications of clinical trials of any size and cohort studies with more than 10 patients that included pain and/or fatigue based on patient-reported outcomes (PROs) and/or physician-assessed measures in adults following treatment with RCI for RA, SLE, symptomatic sarcoidosis, uveitis, or keratitis. Literature searches identified eight studies that met these criteria. Four studies (reported in five publications) were in patients with RA or SLE, two in patients with sarcoidosis, one in patients with uveitis, and one in patients with noninfectious keratitis. Across the different types of studies assessed (clinical trials, chart reviews, real-world evidence), the results were consistent with respect to the impact of RCI treatment on improving pain and fatigue. As summarized in this review, data from patient- and physician-reported outcome measures in eight studies demonstrate that, in addition to improving more traditional efficacy measures, RCI may also improve pain and fatigue in patients with RA, SLE, symptomatic sarcoidosis, uveitis, and noninfectious keratitis. Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are chronic autoimmune diseases. Clinical studies of drugs for these diseases do not often ask patients how they feel after treatment. Despite treatment, many people with these diseases have pain and feel tired. Repository corticotropin injection (RCI) is a prescription drug for patients with RA, SLE, and other chronic immune diseases. We reviewed the results of published studies with data on pain and fatigue from patients treated with RCI. Four studies were in patients with RA or SLE. Two studies were in patients with symptomatic sarcoidosis. One study was in patients with uveitis. One study was in patients with noninfectious keratitis. These eight studies show that adding RCI to standard treatment lowers pain and fatigue in some patients. It would be helpful to measure pain and fatigue in future clinical studies of drugs for patients with chronic immune diseases.
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Affiliation(s)
| | | | - Kyle Hayes
- Mallinckrodt Pharmaceuticals Inc., Hampton, NJ, USA
| | | | - George J Wan
- Mallinckrodt Pharmaceuticals Inc., Hampton, NJ, USA.
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4
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Epstein RS, Nelms J, Moran D, Girman C, Huang H, Chioda M. Treatment patterns and burden of myelosuppression for patients with small cell lung cancer: A SEER-medicare study. Cancer Treat Res Commun 2022; 31:100555. [PMID: 35421820 DOI: 10.1016/j.ctarc.2022.100555] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE To depict the treatment journey for patients with small cell lung cancer (SCLC) and evaluate health care resource utilization (HCRU) associated with myelosuppression, a complication induced by chemotherapy or chemotherapy plus radiation therapy. PATIENTS AND METHODS This was a descriptive, retrospective study of patients with SCLC aged ≥65 years, identified from linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data curated between January 2012 and December 2015. Treatment types (chemotherapy, radiation therapy, surgery) were classified as first, second, or third line, depending on the temporal sequence in which regimens were prescribed. For each year, the proportions of patients completing 4- or 6-cycle chemotherapy regimens, with hospital admissions associated with myelosuppression, or who used granulocyte colony-stimulating factors (G-CSFs), blood/platelet transfusions, or erythropoiesis-stimulating agents (ESAs), were calculated. RESULTS Chemotherapy was administered as initial treatment in 7,807/11,907 (65.6%) patients whose treatment journey was recorded. Approximately one-third (n = 3,985) subsequently received radiation therapy. In total, 5,791 (57.8%) patients completed the guideline-recommended 4-6 cycles of chemotherapy. Among all chemotherapy-treated patients, 10,370 (74.3%) experienced ≥1 inpatient admission associated with myelosuppression (anemia, 7,366 [52.8%]; neutropenia, 4,642 [33.3%]; thrombocytopenia, 2,375 [17.0%]; pancytopenia, 1,983 [14.2%]). Supportive care interventions included G-CSF (6,756 [48.4%] patients), ESAs (1,534 [11.0%]), and transfusions (3,674 [26.3%]). CONCLUSION Chemotherapy remains a cornerstone of care for patients with SCLC. Slightly over half of patients completed the recommended number of cycles, underscoring the frailty of patients and aggressiveness of SCLC. HCRU associated with myelosuppression was prominent, suggesting a substantial burden on older patients with SCLC.
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Affiliation(s)
- Robert S Epstein
- Epstein Health, LLC., 50 Tice Blvd., Suite 340, Woodcliff Lake, NJ 07677, United States of America
| | - Jerrod Nelms
- Lucyna Health and Safety Solutions, LLC., Lakeland, FL 33810, United States of America; CERobs Consulting, LLC., Chapel Hill, NC 27516, United States of America.
| | - Donald Moran
- G1 Therapeutics, Inc., 700 Park Offices Drive, Suite 200, Research Triangle Park, NC 27709, United States of America
| | - Cynthia Girman
- CERobs Consulting, LLC., Chapel Hill, NC 27516, United States of America
| | - Huan Huang
- G1 Therapeutics, Inc., 700 Park Offices Drive, Suite 200, Research Triangle Park, NC 27709, United States of America
| | - Marc Chioda
- G1 Therapeutics, Inc., 700 Park Offices Drive, Suite 200, Research Triangle Park, NC 27709, United States of America
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5
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Epstein RS, Basu Roy UK, Aapro M, Salimi T, Moran D, Krenitsky J, Leone-Perkins ML, Girman C, Schlusser C, Crawford J. Cancer Patients' Perspectives and Experiences of Chemotherapy-Induced Myelosuppression and Its Impact on Daily Life. Patient Prefer Adherence 2021; 15:453-465. [PMID: 33658769 PMCID: PMC7920579 DOI: 10.2147/ppa.s292462] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/19/2021] [Indexed: 01/10/2023] Open
Abstract
PURPOSE To evaluate which side effects of chemotherapy are considered most burdensome by patients with cancer, identify which health care professionals pay most attention to symptoms associated with chemotherapy-induced myelosuppression (CIM) from the patient perspective, and capture the "patient voice" describing how CIM impacts their daily lives. PARTICIPANTS AND METHODS Online survey of participants with breast, lung, or colorectal cancer who had received chemotherapy within the past 12 months and experienced ≥1 episode of CIM in the past year. Participants were asked to answer close-ended questions and provide qualitative responses to: "In your own words, please describe how side effects from myelosuppression have impacted your life." RESULTS Among 301 survey participants, fatigue was the most frequently reported side effect of chemotherapy; 55% of participants rated fatigue as highly bothersome (9 or 10 on a 1-10 scale of "bothersomeness"). Participants rated symptoms associated with CIM, including fatigue, weakened immune system (infections), bleeding and/or bruising, and shortness of breath, as being as bothersome as other side effects of chemotherapy, including alopecia, neuropathy, and nausea/vomiting. Overall, 24-43% of participants thought that CIM and its symptoms had a negative impact on their daily lives, including their ability to complete tasks at home and work, and to socialize. Qualitative responses supported these findings; participants highlighted that CIM-related symptoms, particularly fatigue and fear of infections, affected their ability to be physically active, complete work, or continue meaningful relationships with friends and family. CONCLUSION Participants described a real-world impact of CIM that often isolates them from family and friends, and means that they are unable to work or perform tasks of daily living. Using measures that help patients to recognize and communicate the signs and symptoms of CIM might increase the likelihood of maintaining daily lives as close to normal as possible, during and after chemotherapy treatment.
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Affiliation(s)
- Robert S Epstein
- Epstein Health, LLC., Woodcliff Lake, NJ, USA
- Correspondence: Robert S Epstein Epstein Health, LLC., Woodcliff Lake, NJ, 07677, USATel +1 201-285-5800 Email
| | | | | | | | - Donald Moran
- G1 Therapeutics Ltd., Research Triangle Park, NC, USA
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6
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Webster-Clark M, Stürmer T, Wang T, Man K, Marinac-Dabic D, Rothman KJ, Ellis AR, Gokhale M, Lunt M, Girman C, Glynn RJ. Using propensity scores to estimate effects of treatment initiation decisions: State of the science. Stat Med 2020; 40:1718-1735. [PMID: 33377193 DOI: 10.1002/sim.8866] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 02/02/2023]
Abstract
Confounding can cause substantial bias in nonexperimental studies that aim to estimate causal effects. Propensity score methods allow researchers to reduce bias from measured confounding by summarizing the distributions of many measured confounders in a single score based on the probability of receiving treatment. This score can then be used to mitigate imbalances in the distributions of these measured confounders between those who received the treatment of interest and those in the comparator population, resulting in less biased treatment effect estimates. This methodology was formalized by Rosenbaum and Rubin in 1983 and, since then, has been used increasingly often across a wide variety of scientific disciplines. In this review article, we provide an overview of propensity scores in the context of real-world evidence generation with a focus on their use in the setting of single treatment decisions, that is, choosing between two therapeutic options. We describe five aspects of propensity score analysis: alignment with the potential outcomes framework, implications for study design, estimation procedures, implementation options, and reporting. We add context to these concepts by highlighting how the types of comparator used, the implementation method, and balance assessment techniques have changed over time. Finally, we discuss evolving applications of propensity scores.
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Affiliation(s)
| | - Til Stürmer
- Department of Epidemiology, UNC Chapel Hill, Chapel Hill, North Carolina, USA
| | - Tiansheng Wang
- Department of Epidemiology, UNC Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kenneth Man
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK.,Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Danica Marinac-Dabic
- Office of Clinical Evidence and Analysis, FDA Center for Devices and Radiological Health, Silver Springs, Maryland, USA
| | - Kenneth J Rothman
- RTI Health Solutions, Raleigh, North Carolina, USA.,Department of Epidemiology, Boston University, Boston, Massachusetts, USA
| | - Alan R Ellis
- Department of Social Work, NC State University, Raleigh, North Carolina, USA
| | - Mugdha Gokhale
- Department of Epidemiology, UNC Chapel Hill, Chapel Hill, North Carolina, USA.,Pharmacoepidemiology, Center for Observational & Real-World Evidence, Merck, West Point, Pennsylvania, USA
| | - Mark Lunt
- The Arthritis Research UK Epidemiology Unit, University of Manchester, Manchester, UK
| | - Cynthia Girman
- Department of Epidemiology, UNC Chapel Hill, Chapel Hill, North Carolina, USA.,CERobs Consulting, LLC, Chapel Hill, North Carolina, USA
| | - Robert J Glynn
- Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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7
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Dmochowski RR, Thai S, Iglay K, Enemchukwu E, Tee S, Varano S, Girman C, Radican L, Mudd PN, Poole C. Increased risk of incident dementia following use of anticholinergic agents: A systematic literature review and meta-analysis. Neurourol Urodyn 2020; 40:28-37. [PMID: 33098213 PMCID: PMC7821204 DOI: 10.1002/nau.24536] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [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] [Received: 06/01/2020] [Revised: 09/17/2020] [Accepted: 10/01/2020] [Indexed: 12/15/2022]
Abstract
Background/rationale Long‐term treatment with anticholinergic agents may increase the risk of cognitive impairment or dementia. This systematic literature review and meta‐analysis aimed to assess the impact of ≥3 months of exposure to anticholinergics as a class on the risk of dementia, mild cognitive impairment, and change in cognitive function. The impact of anticholinergic agents specifically used to treat overactive bladder was also evaluated. Materials and Methods A systematic literature review was conducted to identify English language articles evaluating the impact of anticholinergic use for ≥3 months on dementia or cognitive function in adult patients. Databases searched included PubMed, Embase, and the Cochrane Library. Meta‐analyses were conducted using random‐effects models; 95% confidence intervals (CIs) and 95% prediction intervals (PIs) were reported. Results A total of 2122 records were identified. Out of those, 21 studies underwent qualitative synthesis and 6 reported endpoints relevant for inclusion in a meta‐analysis assessing the risk of incident dementia. The overall rate ratio for incident dementia was 1.46 (95% CI: 1.17–1.81; 95% PI: 0.70–3.04; n = 6). The risk of incident dementia increased with increasing exposure (n = 3). In addition, two studies from the meta‐analysis reported an increased risk of dementia with ≥3 months of use of bladder antimuscarinics (adjusted odds ratios ranged from 1.21 to 1.65, depending on exposure category). Conclusion Anticholinergic use for ≥3 months increased the risk of dementia on average by an estimated 46% versus nonuse. This relationship was consistent in studies assessing overactive bladder medications. The risk of developing dementia should be carefully considered in the context of potential benefit before prescribing anticholinergics.
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Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sydney Thai
- Department of Pharmacoepidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,CERobs Consulting, LLC, Chapel Hill, North Carolina, USA
| | - Kristy Iglay
- CERobs Consulting, LLC, Chapel Hill, North Carolina, USA.,Laylen Scientific Solutions, LLC, Flemington, New Jersey, USA
| | - Ekene Enemchukwu
- Department of Urology, School of Medicine, Stanford University, Stanford, California, USA
| | - Silvia Tee
- School of Medicine, Section of Geriatric Medicine - Primary Care and Population Health, Stanford University, Stanford, California, USA
| | - Susann Varano
- Clinical Research Consulting, Milford, Connecticut, USA
| | - Cynthia Girman
- Department of Pharmacoepidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,CERobs Consulting, LLC, Chapel Hill, North Carolina, USA
| | - Larry Radican
- Peloton Advantage, an Open Health Company, Parsippany, New Jersey, USA
| | - Paul N Mudd
- Clinical Development, Urovant Sciences, Inc., Durham, North Carolina, USA
| | - Charles Poole
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
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8
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Kulkarni M, Foraker RE, McNeill AM, Girman C, Golden SH, Rosamond WD, Duncan B, Schmidt MI, Tuomilehto J. Evaluation of the modified FINDRISC to identify individuals at high risk for diabetes among middle-aged white and black ARIC study participants. Diabetes Obes Metab 2017; 19:1260-1266. [PMID: 28321981 PMCID: PMC5568921 DOI: 10.1111/dom.12949] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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] [Received: 12/04/2016] [Revised: 03/16/2017] [Accepted: 03/17/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate a modified Finnish Diabetes Risk Score (FINDRISC) for predicting the risk of incident diabetes among white and black middle-aged participants from the Atherosclerosis Risk in Communities (ARIC) study. RESEARCH DESIGN AND METHODS We assessed 9754 ARIC cohort participants who were free of diabetes at baseline. Logistic regression and receiver operator characteristic (ROC) curves were used to evaluate a modified FINDRISC for predicting incident diabetes after 9 years of follow-up, overall and by race/gender group. The modified FINDRISC used comprised age, body mass index, waist circumference, blood pressure medication and family history. RESULTS The mean FINDRISC (range, 2 [lowest risk] to 17 [highest risk]) for black women was higher (9.9 ± 3.6) than that for black men (7.6 ± 3.9), white women (8.0 ± 3.6) and white men (7.6 ± 3.5). The incidence of diabetes increased generally across deciles of FINDRISC for all 4 race/gender groups. ROC curve statistics for the FINDRISC showed the highest area under the curve for white women (0.77) and the lowest for black men (0.70). CONCLUSIONS We used a modified FINDRISC to predict the 9-year risk of incident diabetes in a biracial US population. The modified risk score can be useful for early screening of incident diabetes in biracial populations, which may be helpful for early interventions to delay or prevent diabetes.
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Affiliation(s)
- Manjusha Kulkarni
- Division of Medical Laboratory Science, School of Health and Rehabilitation Sciences, Ohio State University, Columbus, Ohio
- Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio
| | - Randi E Foraker
- Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio
| | - Ann M McNeill
- Merck Sharp & Dohme Corp., Whitehouse Station, New Jersey
| | - Cynthia Girman
- CERobs Consulting, LLC, Chapel Hill, North Carolina
- Department of Epidemiology, Gillings School of Global Public Health, UNC, Chapel Hill, North Carolina
| | - Sherita H Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings Global School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Bruce Duncan
- Postgraduate Program in Epidemiology, School of Medicine, Federal University of Rio Grande do Sul, Rio Grande do Sul, Brazil
| | - Maria Ines Schmidt
- Postgraduate Program in Epidemiology, School of Medicine, Federal University of Rio Grande do Sul, Rio Grande do Sul, Brazil
| | - Jaakko Tuomilehto
- Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
- Centre for Vascular Prevention, Danube-University Krems, Krems, Austria
- Dasman Diabetes Institute, Safat, Kuwait
- Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
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9
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Gokhale M, Girman C, Chen Y, Pate V, Funk MJ, Stürmer T. Comparison of diagnostic evaluations for cough among initiators of angiotensin converting enzyme inhibitors and angiotensin receptor blockers. Pharmacoepidemiol Drug Saf 2016; 25:512-20. [PMID: 26860956 DOI: 10.1002/pds.3977] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/11/2016] [Accepted: 01/11/2016] [Indexed: 12/27/2022]
Abstract
PURPOSE Differential diagnostic evaluation associated with a drug may bias effect estimates because of an increased detection of preclinical outcomes. Persistent cough is a common side effect with angiotensin-converting enzyme inhibitors (ACEI), and we hypothesized that ACEI initiators would undergo more diagnostic evaluations, potentially leading to diagnosis of preclinical lung cancer. We compared the incidence of cough-related diagnostic evaluations and lung cancer among ACEI versus angiotensin receptor blockers (ARB) initiators. METHODS Using a 20% sample of Medicare claims 2007-2012, we identified initiators of ACEI or ARB, age 66-99 years. Incidence of diagnostic evaluation and lung cancer were compared using adjusted Cox models. Monthly probabilities of workup were compared using proportion differences. RESULTS There were 342 611 and 108 116 ACEI and ARB initiators, respectively. Monthly probability of chest X-rays ranged from minimum 4.7% to maximum 21.2% in the 6 months pre and post-initiation. Differences in incidence of diagnostic procedures in the 6 months after initiation were only minimal (chest X-rays hazard ratio (HR) = 1.12; 95% CI: 1.10-1.14), chest-MRI (0.86, 95% CI: 0.74-0.99), CT-scans (1.09, 95% CI: 0.99-1.18) or bronchoscopies (1.03, 95% CI: 0.83-1.29). Proportion differences for chest X-rays peaked in the month pre-initiation (8.4%, 95% CI: 8.1-8.6) but negligible thereafter. There was no difference in the incidence of lung cancer among ACEI versus ARB initiators (HR = 0.99, 95% CI: 0.84-1.16). CONCLUSION Results indicate minimal differential chest workup after ACEI versus ARB initiation and no difference in lung cancer incidence, but suggest differential workup in the month before the first recorded prescription. The latter may reflect drug use before the first observed pharmacy claim or increased workup before initiation of ACEI therapy. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Mugdha Gokhale
- Department of Epidemiology Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | | | - Yong Chen
- Data Analytics and Observational Methods, Center for Observational & Real World Evidence, Merck & Co., Inc, USA
| | - Virginia Pate
- Department of Epidemiology Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Michele Jonsson Funk
- Department of Epidemiology Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Til Stürmer
- Department of Epidemiology Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
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10
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Reilly MP, Rohatgi A, McMahon K, Wolfe ML, Pinto SC, Rhodes T, Girman C, Rader DJ. Plasma Cytokines, Metabolic Syndrome, and Atherosclerosis in Humans. J Investig Med 2016; 55:26-35. [PMID: 17441409 DOI: 10.2310/6650.2007.06013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) integrate inflammatory and adipose signaling but also have direct vascular effects. We hypothesized that plasma levels of IL-6 and soluble tumor necrosis factor alpha receptor 2 (sol-TNFR2) would be related to coronary atherosclerosis beyond established risk factors and the metabolic syndrome. METHODS We examined the association of IL-6 and sol-TNFR2 with metabolic syndrome, C-reactive protein (CRP), and coronary artery calcification (CAC) in 875 asymptomatic participants in the Study of Inherited Risk of Coronary Atherosclerosis. RESULTS IL-6 levels were 56% higher (p < .001) and sol-TNFR2 levels 16% higher (p < .001) in subjects with metabolic syndrome compared with those without. Both cytokines were associated with CAC beyond age, gender, Framingham risk scores, family history, metabolic syndrome, and CRP (odds ratio and 95% confidence interval of higher CAC for 1 SD increase in log-transformed cytokine levels: 1.23 [1.06-1.43], p = .006 for IL-6 and 1.15 [1.01-1.31], p = .04 for sol-TNFR2). In fact, cytokine levels were independently associated with CAC scores in the subgroup with metabolic syndrome and were additive to the homeostasis model assessment of insulin resistance in predicting CAC. CONCLUSIONS Plasma IL-6 and sol-TNFR2 levels were independently associated with CAC, suggesting a role in integrating innate immune and adipose signaling in promoting atherosclerosis and cardiovascular risk. Measurement of their levels may facilitate cardiovascular risk prediction and targeting of therapeutic strategies.
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Affiliation(s)
- Muredach P Reilly
- Cardiovascular Institute, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6160, USA.
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Gater A, Coon CD, Nelsen LM, Girman C. Unique Challenges in Development, Psychometric Evaluation, and Interpretation of Daily and Event Diaries as Endpoints in Clinical Trials. Ther Innov Regul Sci 2015; 49:813-821. [DOI: 10.1177/2168479015609649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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12
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Lightner D, Krambeck A, Jacobson D, McGree M, Jacobsen S, Lieber M, Roger V, Girman C, St. Sauver J. 1527 SIGNIFICANT NOCTURIA IS ASSOCIATED WITH AN INCREASED RISK OF CORONARY HEART DISEASE AND DEATH. J Urol 2010. [DOI: 10.1016/j.juro.2010.02.1278] [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: 10/19/2022]
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13
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St. Sauver J, Jacobson D, McGree M, Girman C, Lieber M, Nehra A, Jacobsen S. 1633 CORRELATIONS BETWEEN RATES OF DECLINE IN TESTOSTERONE LEVEL AND RATES OF CHANGE IN LOWER URINARY TRACT SYMPTOMS, PROSTATIC ENLARGEMENT, AND MAXIMUM URINARY FLOW RATE. J Urol 2010. [DOI: 10.1016/j.juro.2010.02.1414] [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: 11/25/2022]
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14
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Dekker J, Rijkelijkhuizen J, Alssema M, Holst J, Mari A, Rhodes T, Eekhoff E, Teerlink T, Scheffer P, Nijpels G, Nijpels G, Girman C. Abstract: P409 INCRETINS ARE ASSOCIATED WITH POSTPRANDIAL TRIGYCERIDES. ATHEROSCLEROSIS SUPP 2009. [DOI: 10.1016/s1567-5688(09)70704-4] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Lathia CD, Amakye D, Dai W, Girman C, Madani S, Mayne J, MacCarthy P, Pertel P, Seman L, Stoch A, Tarantino P, Webster C, Williams S, Wagner JA. The value, qualification, and regulatory use of surrogate end points in drug development. Clin Pharmacol Ther 2009; 86:32-43. [PMID: 19474783 DOI: 10.1038/clpt.2009.69] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The acceptance and use of either surrogate end points (SEPs) or efficient clinical end points are associated with greater and more rapid availability of new medicines as compared with disease situations for which clinical end points are inefficient or no surrogates exist. This review of the history of the development, qualification, and acceptance of key SEPs shows that both successes and failures had three key characteristics: (i) apparent biologic plausibility, (ii) prognostic value for the outcome of the disease, and (iii) an association between changes in the SEP and changes in outcome with therapeutic intervention--the three factors recommended for SEPs in the International Conference on Harmonisation's "Statistical Principles for Clinical Trials." We recommend that only prognostic value be an absolute prerequisite for surrogacy, because therapeutic interventions may not exist a priori, and biological plausibility can be subjective. Ideally, all three of these factors would be traded off against one another in a consistent and transparent risk-management process.
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Affiliation(s)
- C D Lathia
- Clinical Pharmacology, Bayer Pharmaceuticals, Montville, New Jersey, USA.
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St. Sauver JL, Jacobsen SJ, Jacobson D, McGree M, Girman C, Nehra A, Lieber M. STATIN AND NON-STEROIDAL ANTI-INFLAMMATORY DRUG USE AND DEVELOPMENT OF UROLOGIC OUTCOMES. J Urol 2009. [DOI: 10.1016/s0022-5347(09)61668-2] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Qasim A, Mehta NN, Tadesse MG, Wolfe ML, Rhodes T, Girman C, Reilly MP. Adipokines, insulin resistance, and coronary artery calcification. J Am Coll Cardiol 2008; 52:231-6. [PMID: 18617073 DOI: 10.1016/j.jacc.2008.04.016] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [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: 01/29/2008] [Revised: 04/25/2008] [Accepted: 04/28/2008] [Indexed: 02/08/2023]
Abstract
OBJECTIVES We evaluated the hypothesis that plasma levels of adiponectin and leptin are independently but oppositely associated with coronary artery calcification (CAC), a measure of subclinical atherosclerosis. In addition, we assessed which biomarkers of adiposity and insulin resistance are the strongest predictors of CAC beyond traditional risk factors, metabolic syndrome, and plasma C-reactive protein (CRP). BACKGROUND Adipokines are fat-secreted biomolecules with pleiotropic actions that converge in diabetes and cardiovascular disease. METHODS We examined the association of plasma adipocytokines with CAC in 860 asymptomatic, nondiabetic participants in the SIRCA (Study of Inherited Risk of Coronary Atherosclerosis). RESULTS Plasma adiponectin and leptin levels had opposite and distinct associations with adiposity, insulin resistance, and inflammation. Plasma leptin was positively (top vs. bottom quartile) associated with higher CAC after adjustment for age, gender, traditional risk factors, and Framingham risk scores (tobit regression ratio 2.42 (95% confidence interval [CI]: 1.48 to 3.95; p = 0.002) and further adjustment for metabolic syndrome and CRP (tobit regression ratio: 2.31; 95% CI: 1.36 to 3.94; p = 0.002). In contrast, adiponectin levels were not associated with CAC. Comparative analyses suggested that levels of leptin, interleukin-6, and soluble tumor necrosis factor receptor-2, as well as the homeostasis model assessment of insulin resistance (HOMA-IR) index, predicted CAC scores, but only leptin and HOMA-IR provided value beyond risk factors, metabolic syndrome, and CRP. CONCLUSIONS In SIRCA, although both leptin and adiponectin levels were associated with metabolic and inflammatory markers, only leptin was a significant independent predictor of CAC. Of several metabolic markers, leptin and the HOMA-IR index had the most robust, independent associations with CAC.
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Affiliation(s)
- Atif Qasim
- Cardiovascular Institute and Institute for Translational Medicine and Therapeutics, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Abstract
BACKGROUND Different definitions of the metabolic syndrome have been proposed. Their value in a clinical setting to assess cardiovascular disease (CVD) risk is still unclear. We compared the definitions proposed by the National Cholesterol Education Program Adult Treatment Panel III (NCEP), World Health Organization (WHO), European Group for the Study of Insulin Resistance (EGIR), and American College of Endocrinology (ACE) with respect to the prevalence of the metabolic syndrome and the association with 10-year risk of fatal and nonfatal CVD. METHODS AND RESULTS The Hoorn Study is a population-based cohort study. The present study population comprised 615 men and 749 women aged 50 to 75 years and without diabetes or a history of CVD at baseline in 1989 to 1990. The prevalence of the metabolic syndrome at baseline ranged from 17% to 32%. The NCEP definition was associated with about a 2-fold increase in age-adjusted risk of fatal CVD in men and nonfatal CVD in women. For the WHO, EGIR, and ACE definitions, these hazard ratios were slightly lower. Risk increased with the number of risk factors. Elevated insulin levels were more prevalent in subjects with multiple risk factors, but metabolic syndrome definitions including elevated insulin level were not more strongly associated with risk. CONCLUSIONS The metabolic syndrome, however defined, is associated with an approximate 2-fold increased risk of incident cardiovascular morbidity and mortality in a European population. In clinical practice, a more informative assessment can be obtained by taking into account the number of individual risk factors.
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Affiliation(s)
- Jacqueline M Dekker
- The Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Bailey A, Martin ML, Girman C, McNaughton-Collins M, Barry MJ. DEVELOPMENT OF A MULTIREGIONAL UNITED STATES SPANISH VERSION OF THE INTERNATIONAL PROSTATE SYMPTOM SCORE AND THE BENIGN PROSTATIC HYPERPLASIA IMPACT INDEX. J Urol 2005; 174:1896-901; discussion 1901. [PMID: 16217332 DOI: 10.1097/01.ju.0000177072.59090.f7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The International Prostate Symptom Score (I-PSS) and Benign Prostatic Hyperplasia Impact Index (BII) have gained widespread use in clinical practice and clinical trials. Although Spanish translations of the I-PSS are available, to our knowledge none was developed for the Spanish speaking population in the United States using a methodology to ensure appropriateness for the diverse United States Spanish speaking population. An existing translation intended for another Spanish speaking country, such as Mexico, or a translation developed without input from each language group may not be understood by those who immigrated from other Latin American regions. Hence, the development of a Spanish translation for the United States should involve input from translators from each region of Latin America. MATERIALS AND METHODS We reviewed and modified an existing United States Spanish translation of I-PSS using a multiregional reconciliation panel comprised of representatives from each of the major Spanish language groups in the United States. For BII full translation methodology was used to develop a translation for the United States, including 2 forward translations using translators from more than 1 region, a multiregional reconciliation panel meeting, a back translation evaluation, cognitive debriefing interviews with representatives from each language group, developer review, a final evaluation for consistency and proofreading. RESULTS The revised I-PSS better reflects common Spanish wording in the United States, while the BII translation was confirmed to be comprehended by Spanish speakers in the United States originating from multiple regions of Latin America. CONCLUSIONS United States Spanish translations of patient reported outcome measures should consider the diversity of the growing Spanish speaking population in the United States to ensure comprehension across the broad population originating from the multiple regions of Latin America.
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Affiliation(s)
- A Bailey
- Health Research Associates, Inc. Seattle, Washington, USA
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Reilly MP, Wolfe ML, Rhodes T, Girman C, Mehta N, Rader DJ. Measures of insulin resistance add incremental value to the clinical diagnosis of metabolic syndrome in association with coronary atherosclerosis. Circulation 2004; 110:803-9. [PMID: 15289378 DOI: 10.1161/01.cir.0000138740.84883.9c] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.4] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND Whether measures of insulin resistance provide incremental information regarding atherosclerotic cardiovascular disease beyond current National Cholesterol Education Program (NCEP) Adult Treatment Panel III metabolic syndrome (MetSyn) criteria or inflammatory markers is uncertain. METHODS AND RESULTS We examined the association of insulin resistance and MetSyn with coronary artery calcification (CAC) in 840 asymptomatic nondiabetic subjects. Both NCEP and World Health Organization-defined MetSyn were associated (ordinal regression odds ratio [OR] and 95% confidence intervals for NCEP-defined MetSyn) with CAC after controlling for age, non-MetSyn risk factors, and plasma CRP levels (OR, 1.93 [1.43 to 2.60], P<0.001) and after further controlling for homeostasis model assessment index (HOMA) (OR, 1.56 [1.14 to 2.15], P=0.006). Conversely, HOMA was significantly associated with CAC after adjusting for age, non-MetSyn risk factors, and CRP levels (OR, 1.62 [1.31 to 2.01], P<0.001) and after further adjusting for NCEP-defined MetSyn (OR, 1.45 [1.16 to 1.82], P=0.007). Addition of HOMA to the NCEP MetSyn significantly improved the association with CAC, but addition of CRP data to MetSyn or HOMA did not. CONCLUSIONS Both MetSyn and HOMA index were associated with coronary atherosclerosis independent of established risk factors, including CRP. These findings support the use of biomarkers of insulin resistance in addition to NCEP MetSyn criteria in assessing cardiovascular disease risk.
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Affiliation(s)
- Muredach P Reilly
- Cardiovascular Division and Center for Experimental Therapeutics, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pa, USA.
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Chandler JM, Martin AR, Girman C, Ross PD, Love-McClung B, Lydick E, Yawn BP. Reliability of an Osteoporosis-Targeted Quality of Life Survey Instrument for use in the community: OPTQoL. Osteoporos Int 1998; 8:127-35. [PMID: 9666935 DOI: 10.1007/bf02672508] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [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: 11/28/2022]
Abstract
A brief Osteoporosis-Targeted Quality of Life (OPTQoL) questionnaire was previously developed as a cross-sectional survey instrument to assess the community impact of osteoporosis on quality of life in women. The initial development process involving item generation through focus groups, item reduction, and content and construct validation yielded a 36-item questionnaire with three domains (physical difficulty, adaptations and fears) and 10 health-related questions. In the present study, test-retest reliability and internal consistency of the questionnaire were assessed in a mail-based study with two clinical sites. Two hundred women (50 with severe osteoporosis, 50 with osteopenia, 50 with normal bone mineral density (BMD) and 50 with osteoarthritis and normal BMD), aged 43-84 years, completed the self-administered questionnaire initially and again about 2 weeks later. Using weighted kappas, agreement between questionnaire administrations ranged from 0.60 to 0.80 for most of the individual items. Intraclass correlation coefficients to assess reliability for the domain scores were 0.93 (physical difficulty), 0.82 (adaptations) and 0.88 (fears). Internal consistency of each of the domains was also high, with Cronbach's alpha coefficients ranging from 0.89 to 0.91. Four items were dropped from the 36-item questionnaire due to high percentage of 'not applicable' responses. Results of the analyses support the validity and reliability of this instrument as a cross-sectional survey tool for assessing the impact of osteoporosis on quality of life in women living in the community. The questionnaire has been translated and culturally adapted into seven languages to allow cross-cultural studies of the community impact of osteoporosis.
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Affiliation(s)
- J M Chandler
- Merck Research Laboratories, Department of Epidemiology, West Point, PA 19486, USA
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Intoccia AP, Levandoski P, Joseph G, Wittendorf R, Girman C, Walkenstein SS, Hwang BY. Metabolism of 7,8-dichloro-1,2,3,4-tetrahydroisoquinoline, a phenylethanolamine N-methyltransferase inhibitor. I. Disposition following administration to the rat and dog. Xenobiotica 1981; 11:301-9. [PMID: 7293220 DOI: 10.3109/00498258109045308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Intoccia AP, Walkenstein SS, Joseph G, Wittendorf R, Girman C, Walz DT, Actor P, Weisbach J. Distribution in normal and inflammatory tissue of a new semisynthetic cephalosporin, SK&F 75073. J Antibiot (Tokyo) 1978; 31:1188-94. [PMID: 721712 DOI: 10.7164/antibiotics.31.1188] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
SK&F 75073 is a new cephalosporin with broad spectrum antibacterial activity. SK&F 75073-14C and cefazolin-35S were administered separately to groups of rats as a single intramuscular dose of 20 mg/kg. Tissues with highest drug levels 15 minutes following dose were as follows: (SK&F 75073/cefazolin levels), kidney - 86/70 microgram/g, liver - 33/22 microgram/g, lung - 29/17 microgram/g, heart - 23/10 microgram/g, adrenal - 13/7 microgram/g. Plasma levels at peak were 134 microgram SK&F 75073/ml (half-life, 1.9 hours) and 72 microgram cefazolin/ml (half-life, 0.75 hours). Dose excreted in 24 hours was: SK&F 75073, urine 66% and feces 27%; cefazolin, urine 96% and feces 2%. Both antibiotics were also administered, at 20 mg/kg, to rats with the carrageenan-induced inflammatory pouches. Exudate from these pouches contained from 2 to 10 times more SK&F 75073 than cefazolin. Radioassay and bioassay of these substances in the exudate gave similar results. Serum protein binding ranged from 96 approximately 98% for SK&F 75073 and 34 approximately 69% for cefazolin. Data indicated that highly protein bound SK&F 75073 enters tissues and tissue fluid to a greater extent than the lesser bound but therapeutically proven antibiotic agent cefazolin.
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