Impact of hysterectomy on analgesic, psychoactive and neuroactive drug use in women with endometriosis: nationwide cohort study

Objective

To evaluate how hysterectomy affects the prescription of analgesic, psychotropic and neuroactive drugs in women with endometriosis using population‐based nationwide registers.

Design

Nationwide cohort study.

Setting

Swedish national registers, from 1 January 2009 to 31 December 2018.

Population

Women with benign disease undergoing a total hysterectomy during the 4‐year period of 2012–2015. Women with endometriosis (n = 1074) were identified and compared with women who did not have endometriosis (n = 10 890).

Methods

Prospectively collected data from two population‐based registers were linked: the Swedish National Quality Register of Gynaecological Surgery and the Swedish National Drug Register. Multivariate logistic regression was used as the main statistical method.

Main outcome measures

Changes in drug prescription over time for 3 years prior to and 3 years after hysterectomy.

Results

The frequency of prescription of analgesics was higher in women with endometriosis compared with women without endometriosis (OR 2.2, 95% CI 1.7–2.9). Among women with endometriosis, the prescription of analgesics (OR 1.0, 95% CI 0.8–1.2) did not decrease 3 years after hysterectomy compared with the 3 years prior to surgery. There was also a significantly higher rate of prescription of psychoactive (OR 1.6, 95% CI 1.4–2.0) and neuroactive drugs (OR 1.9, 95% CI 1.3–2.7) in the long term postoperatively.

Conclusions

In women undergoing hysterectomy, endometriosis was associated with a higher prescription rate of analgesics. In the endometriosis group the prescription of analgesic, psychoactive and neuroactive drugs did not decrease when comparing prescription rates for the 3 years prior to and the 3 years after surgery.

Tweetable abstract

In women with endometriosis, the long‐term prescription of analgesics did not decrease after hysterectomy.

In women with endometriosis, the long‐term prescription of analgesics did not decrease after hysterectomy.

Five-year costs from a randomised comparison of bilateral and single internal thoracic artery grafts

BACKGROUND

The use of bilateral internal thoracic arteries (BITA) for coronary artery bypass grafting (CABG) may improve survival compared with CABG using single internal thoracic arteries (SITA). We assessed the long-term costs of BITA compared with SITA.

METHODS

Between June 2004 and December 2007, 3102 patients from 28 hospitals in seven countries were randomised to CABG surgery using BITA (n=1548) or SITA (n=1554). Detailed resource use data were collected from the initial hospital episode and annually up to 5 years. The associated costs of this resource use were assessed from a UK perspective with 5 year totals calculated for each trial arm and pre-selected patient subgroups.

RESULTS

Total costs increased by approximately £1000 annually in each arm, with no significant annual difference between trial arms. Cumulative costs per patient at 5-year follow-up remained significantly higher in the BITA group (£18 629) compared with the SITA group (£17 480; mean cost difference £1149, 95% CI £330 to £1968, p=0.006) due to the higher costs of the initial procedure. There were no significant differences between the trial arms in the cost associated with healthcare contacts, medication use or serious adverse events.

CONCLUSIONS

Higher index costs for BITA were still present at 5-year follow-up mainly driven by the higher initial cost with no subsequent difference emerging between 1 year and 5 years of follow-up. The overall cost-effectiveness of the two procedures, to be assessed at the primary endpoint of the 10-year follow-up, will depend on composite differences in costs and quality-adjusted survival.

TRIAL REGISTRATION NUMBER

ISRCTN46552265.

Scoping review on interventions to improve adherence to reporting guidelines in health research

OBJECTIVES

The goal of this study is to identify, analyse and classify interventions to improve adherence to reporting guidelines in order to obtain a wide picture of how the problem of enhancing the completeness of reporting of biomedical literature has been tackled so far.

DESIGN

Scoping review.

SEARCH STRATEGY

We searched the MEDLINE, EMBASE and Cochrane Library databases and conducted a grey literature search for (1) studies evaluating interventions to improve adherence to reporting guidelines in health research and (2) other types of references describing interventions that have been performed or suggested but never evaluated. The characteristics and effect of the evaluated interventions were analysed. Moreover, we explored the rationale of the interventions identified and determined the existing gaps in research on the evaluation of interventions to improve adherence to reporting guidelines.

RESULTS

109 references containing 31 interventions (11 evaluated) were included. These were grouped into five categories: (1) training on the use of reporting guidelines, (2) improving understanding, (3) encouraging adherence, (4) checking adherence and providing feedback, and (5) involvement of experts. Additionally, we identified lack of evaluated interventions (1) on training on the use of reporting guidelines and improving their understanding, (2) at early stages of research and (3) after the final acceptance of the manuscript.

CONCLUSIONS

This scoping review identified a wide range of strategies to improve adherence to reporting guidelines that can be taken by different stakeholders. Additional research is needed to assess the effectiveness of many of these interventions.

DELTA2 guidance on choosing the target difference and undertaking and reporting the sample size calculation for a randomised controlled trial

Background

A key step in the design of a RCT is the estimation of the number of participants needed in the study. The most common approach is to specify a target difference between the treatments for the primary outcome and then calculate the required sample size. The sample size is chosen to ensure that the trial will have a high probability (adequate statistical power) of detecting a target difference between the treatments should one exist.

The sample size has many implications for the conduct and interpretation of the study. Despite the critical role that the target difference has in the design of a RCT, the way in which it is determined has received little attention. In this article, we summarise the key considerations and messages from new guidance for researchers and funders on specifying the target difference, and undertaking and reporting a RCT sample size calculation. This article on choosing the target difference for a randomised controlled trial (RCT) and undertaking and reporting the sample size calculation has been dual published in the BMJ and BMC Trials journals

Methods

The DELTA² (Difference ELicitation in TriAls) project comprised five major components: systematic literature reviews of recent methodological developments (stage 1) and existing funder guidance (stage 2); a Delphi study (stage 3); a two-day consensus meeting bringing together researchers, funders and patient representatives (stage 4); and the preparation and dissemination of a guidance document (stage 5).

Results and Discussion

The key messages from the DELTA² guidance on determining the target difference and sample size calculation for a randomised caontrolled trial are presented. Recommendations for the subsequent reporting of the sample size calculation are also provided.

DELTA2 guidance on choosing the target difference and undertaking and reporting the sample size calculation for a randomised controlled trial

BACKGROUND

A key step in the design of a RCT is the estimation of the number of participants needed in the study. The most common approach is to specify a target difference between the treatments for the primary outcome and then calculate the required sample size. The sample size is chosen to ensure that the trial will have a high probability (adequate statistical power) of detecting a target difference between the treatments should one exist. The sample size has many implications for the conduct and interpretation of the study. Despite the critical role that the target difference has in the design of a RCT, the way in which it is determined has received little attention. In this article, we summarise the key considerations and messages from new guidance for researchers and funders on specifying the target difference, and undertaking and reporting a RCT sample size calculation. This article on choosing the target difference for a randomised controlled trial (RCT) and undertaking and reporting the sample size calculation has been dual published in the BMJ and BMC Trials journals METHODS: The DELTA² (Difference ELicitation in TriAls) project comprised five major components: systematic literature reviews of recent methodological developments (stage 1) and existing funder guidance (stage 2); a Delphi study (stage 3); a two-day consensus meeting bringing together researchers, funders and patient representatives (stage 4); and the preparation and dissemination of a guidance document (stage 5).

RESULTS AND DISCUSSION

The key messages from the DELTA² guidance on determining the target difference and sample size calculation for a randomised caontrolled trial are presented. Recommendations for the subsequent reporting of the sample size calculation are also provided.

Choosing the target difference and undertaking and reporting the sample size calculation for a randomised controlled trial - the development of the DELTA2 guidance

BACKGROUND

A key step in the design of a randomised controlled trial is the estimation of the number of participants needed. The most common approach is to specify a target difference in the primary outcome between the randomised groups and then estimate the corresponding sample size. The sample size is chosen to provide reassurance that the trial will have high statistical power to detect the target difference at the planned statistical significance level. Alternative approaches are also available, though most still require specification of a target difference. The sample size has many implications for the conduct of the study, as well as incurring scientific and ethical aspects. Despite the critical role of the target difference for the primary outcome in the design of a randomised controlled trial (RCT), the manner in which it is determined has received little attention. This article reports the development of the DELTA² guidance on the specification and reporting of the target difference for the primary outcome in a sample size calculation for a RCT.

METHODS

The DELTA² (Difference ELicitation in TriAls) project has five components comprising systematic literature reviews of recent methodological developments (stage 1) and existing funder guidance (stage 2), a Delphi study (stage 3), a 2-day consensus meeting bringing together researchers, funders and patient representatives (stage 4), and the preparation and dissemination of a guidance document (stage 5).

RESULTS

The project started in April 2016. The literature search identified 28 articles of methodological developments relevant to a method for specifying a target difference. A Delphi study involving 69 participants, along with a 2-day consensus meeting were conducted. In addition, further engagement sessions were held at two international conferences. The main guidance text was finalised on April 18, 2018, after revision informed by feedback gathered from stages 2 and 3 and from funder representatives.

DISCUSSION

The DELTA² Delphi study identified a number of areas (such as practical recommendations and examples, greater coverage of different trial designs and statistical approaches) of particular interest amongst stakeholders which new guidance was desired to meet. New relevant references were identified by the review. Such findings influenced the scope, drafting and revision of the guidance. While not all suggestions could be accommodated, it is hoped that the process has led to a more useful and practical document.

Guidelines for Inclusion of Patient-Reported Outcomes in Clinical Trial Protocols: The SPIRIT-PRO Extension

Importance

Patient-reported outcome (PRO) data from clinical trials can provide valuable evidence to inform shared decision making, labeling claims, clinical guidelines, and health policy; however, the PRO content of clinical trial protocols is often suboptimal. The SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement was published in 2013 and aims to improve the completeness of trial protocols by providing evidence-based recommendations for the minimum set of items to be addressed, but it does not provide PRO-specific guidance.

Objective

To develop international, consensus-based, PRO-specific protocol guidance (the SPIRIT-PRO Extension).

Design, Setting, and Participants

The SPIRIT-PRO Extension was developed following the Enhancing Quality and Transparency of Health Research (EQUATOR) Network's methodological framework for guideline development. This included (1) a systematic review of existing PRO-specific protocol guidance to generate a list of potential PRO-specific protocol items (published in 2014); (2) refinements to the list and removal of duplicate items by the International Society for Quality of Life Research (ISOQOL) Protocol Checklist Taskforce; (3) an international stakeholder survey of clinical trial research personnel, PRO methodologists, health economists, psychometricians, patient advocates, funders, industry representatives, journal editors, policy makers, ethicists, and researchers responsible for evidence synthesis (distributed by 38 international partner organizations in October 2016); (4) an international Delphi exercise (n = 137 invited; October 2016 to February 2017); and (5) consensus meeting (n = 30 invited; May 2017). Prior to voting, consensus meeting participants were informed of the results of the Delphi exercise and given data from structured reviews evaluating the PRO protocol content of 3 defined samples of trial protocols.

Results

The systematic review identified 162 PRO-specific protocol recommendations from 54 sources. The ISOQOL Taskforce (n = 21) reduced this to 56 items, which were considered by 138 international stakeholder survey participants and 99 Delphi panelists. The final wording of the SPIRIT-PRO Extension was agreed on at a consensus meeting (n = 29 participants) and reviewed by external group of experts during a consultation period. Eleven extensions and 5 elaborations to the SPIRIT 2013 checklist were recommended for inclusion in clinical trial protocols in which PROs are a primary or key secondary outcome. Extension items focused on PRO-specific issues relating to the trial rationale, objectives, eligibility criteria, concepts used to evaluate the intervention, time points for assessment, PRO instrument selection and measurement properties, data collection plan, translation to other languages, proxy completion, strategies to minimize missing data, and whether PRO data will be monitored during the study to inform clinical care.

Conclusions and Relevance

The SPIRIT-PRO guidelines provide recommendations for items that should be addressed and included in clinical trial protocols in which PROs are a primary or key secondary outcome. Improved design of clinical trials including PROs could help ensure high-quality data that may inform patient-centered care.

Reaching consensus on reporting patient and public involvement (PPI) in research: methods and lessons learned from the development of reporting guidelines

INTRODUCTION

Patient and public involvement (PPI) is inconsistently reported in health and social care research. Improving the quality of how PPI is reported is critical in developing a higher quality evidence base to gain a better insight into the methods and impact of PPI. This paper describes the methods used to develop and gain consensus on guidelines for reporting PPI in research studies (updated version of the Guidance for Reporting Patient and Public Involvement (GRIPP2)).

METHODS

There were three key stages in the development of GRIPP2: identification of key items for the guideline from systematic review evidence of the impact of PPI on health research and health services, a three-phase online Delphi survey with a diverse sample of experts in PPI to gain consensus on included items and a face-to-face consensus meeting to finalise and reach definitive agreement on GRIPP2. Challenges and lessons learnt during the development of the reporting guidelines are reported.

DISCUSSION

The process of reaching consensus is vital within the development of guidelines and policy directions, although debate around how best to reach consensus is still needed. This paper discusses the critical stages of consensus development as applied to the development of consensus for GRIPP2 and discusses the benefits and challenges of consensus development.

A protocol of a cross-sectional study evaluating an online tool for early career peer reviewers assessing reports of randomised controlled trials

INTRODUCTION

Systematic reviews evaluating the impact of interventions to improve the quality of peer review for biomedical publications highlighted that interventions were limited and have little impact. This study aims to compare the accuracy of early career peer reviewers who use an innovative online tool to the usual peer reviewer process in evaluating the completeness of reporting and switched primary outcomes in completed reports.

METHODS AND ANALYSIS

This is a cross-sectional study of individual two-arm parallel-group randomised controlled trials (RCTs) published in the BioMed Central series medical journals, BMJ, BMJ Open and Annals of Emergency Medicine and indexed with the publication type 'Randomised Controlled Trial'. First, we will develop an online tool and training module based (a) on the Consolidated Standards of Reporting Trials (CONSORT) 2010 checklist and the Explanation and Elaboration document that would be dedicated to junior peer reviewers for assessing the completeness of reporting of key items and (b) the Centre for Evidence-Based Medicine Outcome Monitoring Project process used to identify switched outcomes in completed reports of the primary results of RCTs when initially submitted. Then, we will compare the performance of early career peer reviewers who use the online tool to the usual peer review process in identifying inadequate reporting and switched outcomes in completed reports of RCTs at initial journal submission. The primary outcome will be the mean number of items accurately classified per manuscript. The secondary outcomes will be the mean number of items accurately classified per manuscript for the CONSORT items and the sensitivity, specificity and likelihood ratio to detect the item as adequately reported and to identify a switch in outcomes. We aim to include 120 RCTs and 120 early career peer reviewers.

ETHICS AND DISSEMINATION

The research protocol was approved by the ethics committee of the INSERM Institutional Review Board (21 January 2016). The study is based on voluntary participation and informed written consent.

TRIAL REGISTRATION NUMBER

NCT03119376.

Choosing the target difference ('effect size') for a randomised controlled trial - DELTA2 guidance protocol

BACKGROUND

A key step in the design of a randomised controlled trial (RCT) is the estimation of the number of participants needed. By far the most common approach is to specify a target difference and then estimate the corresponding sample size; this sample size is chosen to provide reassurance that the trial will have high statistical power to detect such a difference between the randomised groups (at the planned statistical significance level). The sample size has many implications for the conduct of the study, as well as carrying scientific and ethical aspects to its choice. Despite the critical role of the target difference for the primary outcome in the design of an RCT, the manner in which it is determined has received little attention. This article reports the protocol of the Difference ELicitation in TriAls (DELTA2) project, which will produce guidance on the specification and reporting of the target difference for the primary outcome in a sample size calculation for RCTs.

METHODS/DESIGN

The DELTA2 project has five components: systematic literature reviews of recent methodological developments (stage 1) and existing funder guidance (stage 2); a Delphi study (stage 3); a 2-day consensus meeting bringing together researchers, funders and patient representatives, as well as one-off engagement sessions at relevant stakeholder meetings (stage 4); and the preparation and dissemination of a guidance document (stage 5).

DISCUSSION

Specification of the target difference for the primary outcome is a key component of the design of an RCT. There is a need for better guidance for researchers and funders regarding specification and reporting of this aspect of trial design. The aim of this project is to produce consensus based guidance for researchers and funders.

Lower limb arthroplasty: can we produce a tool to predict outcome and failure, and is it cost-effective? An epidemiological study

Background

Although hip and knee arthroplasties are considered to be common elective cost-effective operations, up to one-quarter of patients are not satisfied with the operation. A number of risk factors for implant failure are known, but little is known about the predictors of patient-reported outcomes.

Objectives

(1) Describe current and future needs for lower limb arthroplasties in the UK; (2) describe important risk factors for poor surgery outcomes and combine them to produce predictive tools (for hip and knee separately) for poor outcomes; (3) produce a Markov model to enable a detailed health economic analysis of hip/knee arthroplasty, and for implementing the predictive tool; and (4) test the practicality of the prediction tools in a pragmatic prospective cohort of lower limb arthroplasty.

Design

The programme was arranged into four work packages. The first three work packages used the data from large existing data sets such as Clinical Practice Research Datalink, Hospital Episode Statistics and the National Joint Registry. Work package 4 established a pragmatic cohort of lower limb arthroplasty to test the practicality of the predictive tools developed within the programme.

Results

The estimated number of total knee replacements (TKRs) and total hip replacements (THRs) performed in the UK in 2015 was 85,019 and 72,418, respectively. Between 1991 and 2006, the estimated age-standardised rates (per 100,000 person-years) for a THR increased from 60.3 to 144.6 for women and from 35.8 to 88.6 for men. The rates for TKR increased from 42.5 to 138.7 for women and from 28.7 to 99.4 for men. The strongest predictors for poor outcomes were preoperative pain/function scores, deprivation, age, mental health score and radiographic variable pattern of joint space narrowing. We found a weak association between body mass index (BMI) and outcomes; however, increased BMI did increase the risk of revision surgery (a 5-kg/m2rise in BMI increased THR revision risk by 10.4% and TKR revision risk by 7.7%). We also confirmed that osteoarthritis (OA) severity and migration pattern of the hip predicted patient-reported outcome measures. The hip predictive tool that we developed performed well, with a correctedR2of 23.1% and had good calibration, with only slight overestimation of Oxford Hip Score in the lowest decile of outcome. The knee tool developed performed less well, with a correctedR2of 20.2%; however, it had good calibration. The analysis was restricted by the relatively limited number of variables available in the extant data sets, something that could be addressed in future studies. We found that the use of bisphosphonates reduced the risk of revision knee and hip surgery by 46%. Hormone replacement therapy reduced the risk by 38%, if used for at least 6 months postoperatively. We found that an increased risk of postoperative fracture was prevented by bisphosphonate use. This result, being observational in nature, will require confirmation in a randomised controlled trial. The Markov model distinguished between outcome categories following primary and revision procedures. The resulting outcome prediction tool for THR and TKR reduced the number and proportion of unsatisfactory outcomes after the operation, saving NHS resources in the process. The highest savings per quality-adjusted life-year (QALY) forgone were reported from the oldest patient subgroups (men and women aged ≥ 80 years), with a reported incremental cost-effectiveness ratio of around £1200 saved per QALY forgone for THRs. In the prospective cohort of arthroplasty, the performance of the knee model was modest (R2 = 0.14) and that of the hip model poor (R2 = 0.04). However, the addition of the radiographic OA variable improved the performance of the hip model (R2 = 0.125 vs. 0.110) and high-sensitivity C-reactive protein improved the performance of the knee model (R2 = 0.230 vs. 0.216). These data will ideally need replication in an external cohort of a similar design. The data are not necessarily applicable to other health systems or countries.

Conclusion

The number of total hip and knee replacements will increase in the next decade. High BMI, although clinically insignificant, is associated with an increased risk of revision surgery and postoperative complications. Preoperative pain/function, the pattern of joint space narrowing, deprivation index and level of education were found to be the strongest predictors for THR. Bisphosphonates and hormone therapy proved to be beneficial for patients undergoing lower limb replacement. The addition of new predictors collected from the prospective cohort of arthroplasty slightly improved the performance of the predictive tools, suggesting that the potential improvements in both tools can be achieved using the plethora of extra variables from the validation cohort. Although currently it would not be cost-effective to implement the predictive tools in a health-care setting, we feel that the addition of extensive risk factors will improve the performances of the predictive tools as well as the Markov model, and will prove to be beneficial in terms of cost-effectiveness. Future analyses are under way and awaiting more promising provisional results.

Future work

Further research should focus on defining and predicting the most important outcome to the patient.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Erratum to: Methods for evaluating medical tests and biomarkers

[This corrects the article DOI: 10.1186/s41512-016-0001-y.].

Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study

OBJECTIVE

To evaluate mildly abnormal liver function test (LFT) results in general practice among patients who do not have known liver disease.

DESIGN

Prospective cohort study of people with abnormal LFT results identified in primary care. Participants were intensively investigated using a common protocol and followed up for 2 years. Substudies investigated the psychological sequelae of abnormal test results, clinicians' reasons for testing, decision options when LFT results were abnormal and early detection of liver fibrosis.

SETTING

Eleven primary-care practices: eight in Birmingham and three in Lambeth.

PARTICIPANTS

Adults with abnormal LFT results who did not have pre-existing or obvious liver disease. Eight analytes were included in the panel of LFTs.

MAIN OUTCOME MEASURES

Statistical tests were used to identify the interactions between clinical features, the initial pattern of abnormal LFT results and (1) specific viral, genetic and autoimmune diseases, such as viral hepatitis, haemochromatosis and primary biliary cirrhosis; (2) a range of other serious diseases, such as metastatic cancer and hypothyroidism; (3) 'fatty liver' not associated with the above; and (4) the absence of detectable disease.

RESULTS

Fewer than 5% of people with abnormal LFT results had a specific disease of the liver, and many of these were unlikely to need treatment. The diagnostic potential of the LFT panel is largely subsumed into just two analytes: alanine aminotransferase (ALT) and alkaline phosphatase (ALP). Gamma-glutamyltransferase (GGT) offers a small increase in sensitivity at the margin at the cost of a large loss of specificity. Eighty-four per cent of abnormal LFT results remain abnormal on retesting 1 month later. In many cases, carrying out a definitive or specific test will be more efficient than repeating LFTs, with a view to specific testing only if the test remains abnormal. An ultrasound diagnosis of 'fatty liver' was present in nearly 40% of patients with abnormal LFTs and a small amount of weight loss over 2 years was associated with a reduced incidence of liver fat. There was a J-shaped relationship between alcohol intake and fatty liver in men. An abnormal LFT result causes temporary anxiety, which does not appear to promote sustained behaviour change.

CONCLUSIONS

Liver disease is rare among people with abnormal LFT results in primary care. Only two analytes (ALT and ALP) are helpful in identifying the majority of liver disease. GGT adds little information in return for a high false-positive rate but it is sensitive to alcohol intake. LFT results seldom revert from abnormal to normal over a 1-month period, and modelling shows that repeating an abnormal LFT panel, as recommended in the current guidelines, is inefficient. LFTs are often undertaken to meet perceived patient need for a blood test, but as they are neither specific nor indicative of any particular disease they are among the least suitable tests for this purpose. Obesity and raised ALT provide strong evidence for a presumptive diagnosis of 'fatty' liver. Abnormal LFTs and 'fatty' liver provoke only short-term anxiety and neither is associated with sustained weight loss. Even a small amount of weight loss reduces liver fat.

FUTURE WORK RECOMMENDATIONS

(1) the cases of 'fatty liver' and controls should be followed up in the long term to identify features that predict development of hepatosteatosis and then cirrhosis; (2) the acceptability of replacing the traditional six- to eight-analyte LFT panel with a drop down menu including the ALT/ALP combination should be evaluated.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Defining publication bias: protocol for a systematic review of highly cited articles and proposal for a new framework

BACKGROUND

Selective publication of studies, which is commonly called publication bias, is widely recognized. Over the years a new nomenclature for other types of bias related to non-publication or distortion related to the dissemination of research findings has been developed. However, several of these different biases are often still summarized by the term 'publication bias'.

METHODS/DESIGN

As part of the OPEN Project (To Overcome failure to Publish nEgative fiNdings) we will conduct a systematic review with the following objectives:- To systematically review highly cited articles that focus on non-publication of studies and to present the various definitions of biases related to the dissemination of research findings contained in the articles identified.- To develop and discuss a new framework on nomenclature of various aspects of distortion in the dissemination process that leads to public availability of research findings in an international group of experts in the context of the OPEN Project.We will systematically search Web of Knowledge for highly cited articles that provide a definition of biases related to the dissemination of research findings. A specifically designed data extraction form will be developed and pilot-tested. Working in teams of two, we will independently extract relevant information from each eligible article.For the development of a new framework we will construct an initial table listing different levels and different hazards en route to making research findings public. An international group of experts will iteratively review the table and reflect on its content until no new insights emerge and consensus has been reached.

DISCUSSION

Results are expected to be publicly available in mid-2013. This systematic review together with the results of other systematic reviews of the OPEN project will serve as a basis for the development of future policies and guidelines regarding the assessment and prevention of publication bias.

Different fatty acid pattern in breast milk of obese compared to normal-weight mothers

INTRODUCTION

The aim of this study was to investigate the fatty acid (FA) pattern in breast milk of obese mothers and their neonates' plasma compared to those of normal weight mothers.

PATIENTS AND METHODS

This was an observational study of 41 obese and 41 normal weight pregnant women. Twenty-nine obese women participating in a weight reduction program were investigated for comparison. FAs were analyzed in breast milk collected at 3 and 10 days and one and two months postnatally and in infant's plasma 3 days after birth.

RESULTS AND CONCLUSIONS

The concentration of long-chain n-3 FA were lower and the ratio n-6/n-3 FA higher in neonates and in consecutive samples of breast milk of obese mothers compared to normal weight mothers. The obese mothers that participated in an intervention program with general dietary advice had FA concentrations approaching that of the normal-weight mothers. The study indicates importance of dietary advice in pregnancy.

P2-12-03: A Prospective Study of the Prognostic Implications of Being a BRCA1 Carrier for Young Onset Breast Cancer Patients

Background

BRCA1 gene carriers frequently develop triple negative breast cancer (TNBC) at young ages. Retrospective studies have reached conflicting conclusions about the prognostic implications of breast cancer diagnosed on a background of a constitutional BRCA1 gene mutation. Many studies have the disadvantages of retrospective design and small numbers or both. The Prospective study of Outcomes in Sporadic versus Hereditary breast cancer (POSH) recruited 3024 patients diagnosed before 41 years of age and treated for breast cancer in the UK between 2000 and 2007 (protocol published: Eccles et al BMC Cancer 2008).

Aim: To investigate the effect of family history and BRCA1 gene mutation status on breast cancer survival in women aged younger than 41 years at diagnosis.

Methods: Cases in which the primary tumour pathology report was not available (2.8% of total) were excluded from this analysis. A completed family history questionnaire was available for 2907 cases (99% of total). The primary end point for this analysis was the development of distant metastases from breast cancer. All patients were younger than the starting age for screening in the UK except for known gene carriers of which there were only 8 in total, the remainder of identified gene carriers were tested after cancer diagnosis or as part of this study. Over 90% of patients received adjuvant or neoadjuvant chemotherapy with over 90% of these receiving an anthracycline based regimen. Kaplan Meier survival analysis and log rank test were used to assess survival differences.

Results: 2937 patients were included in the analysis. Mean and median age at diagnosis was 36 years and the cohort was followed prospectively for a mean and median follow up time of 50 months. Overall distant disease free survival in the whole cohort was only 75% at 5 years. The effect of family history on presentation was explored. Patients who reported a first or second degree relative with breast cancer presented with smaller tumours (20mm compared to 22.5mm, p= 0.006) but no difference in axillary nodal status (p=0.2605). Survival was however significantly better comparing the 499 patients who reported a family history of breast cancer compared with the rest of the cohort (p=0.0164). 539 patients had been tested for mutations in the BRCA1/2 genes and 176 high risk gene BRCA1/BRCA2 carriers were identified. We compared 118 patients with a known BRCA1 gene mutation (almost all diagnosed after the cancer) to the 465 patients with confirmed TNBC (p=0.0118). Survival was significantly better in the BRCA1 carriers (p=0.0118). After excluding 29 gene carriers whose primary tumour showed any of ER, HER2 or PR as positive, the same improved survival trend was seen although significant at the 10% level (p=0.07).

Conclusion: This prospective study indicates that BRCA1 gene carriers clearly do not have a worse prognosis when compared to triple negative breast cancers or young onset breast cancer overall and these early follow up data indicate an improved outlook in gene carriers.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-03.

Effects of coffee and tea consumption on urinary incontinence in female twins

OBJECTIVES

To assess the effect of coffee and tea consumption on symptoms of urinary incontinence.

DESIGN

Population-based study.

SETTING

The Swedish Twin Register.

POPULATION

In 2005, all twins born between 1959 and 1985 in Sweden (n = 42,852) were invited to participate in a web-based survey to screen for common complex diseases and common exposures. The present study was limited to female twins with information about at least one urinary symptoms and coffee and tea consumption (n = 14,031).

MAIN OUTCOME MEASURE

The association between coffee and tea consumption and urinary incontinence, as well as nocturia, was estimated as odds ratios (ORs) with 95% confidence intervals.

RESULTS

Women with a high coffee intake were at lower risk of any urinary incontinence (OR 0.78, 95% CI 0.64-0.98) compared with women not drinking coffee. Coffee intake and incontinence subtypes showed no significant associations whereas high tea consumption was specifically associated with a risk for overactive bladder (OR 1.34, 95% CI 11.07-1.67) and nocturia (OR 1.18, 95% CI 1.01-1.38). Results from co-twin control analysis suggested that the associations observed in logistic regression were mainly the result of familial effects.

CONCLUSIONS

This study suggests that coffee and tea consumption has a limited effect on urinary incontinence symptoms. Familial and genetic effects may have confounded the associations observed in previous studies.

Influence of hysterectomy on fistula formation in women with diverticulitis

Background

Diverticulitis is a risk factor for fistula formation but little is known about the influence of hysterectomy in this association. A population-based nationwide matched cohort study was performed to determine the risk of fistula formation in hysterectomized women with, and without, diverticulitis.

Methods

Women who had a hysterectomy between 1973 and 2003, and a matched control cohort, were identified from the Swedish Inpatient Register. Incidence of diverticulitis and fistula surgery was determined by cross-linkage to the Register, and risk was estimated using a Cox regression model.

Results

In a cohort of 168 563 hysterectomized and 614 682 non-hysterectomized women (mean follow-up 11·0 and 11·5 years respectively), there were 14 051 cases of diverticulitis and 851 fistulas. Compared with women who had neither hysterectomy nor diverticulitis, the risk of fistula surgery increased fourfold in hysterectomized women without diverticulitis (hazard ratio (HR) 4·0 (95 per cent confidence interval (c.i.) 3·5 to 4·7)), sevenfold in non-hysterectomized women with diverticulitis (HR 7·6 (4·8 to 12·1)) and 25-fold in hysterectomized women with diverticulitis (HR 25·2 (15·5 to 41·2)).

Conclusion

Diverticulitis, and to a lesser extent hysterectomy, is strongly associated with the risk of fistula formation. Hysterectomized women with diverticulitis have the highest risk of developing surgically managed fistula.