Association of pregnancy complications/risk factors with the development of future long-term health conditions in women: overarching protocol for umbrella reviews

INTRODUCTION

With good medical care, most pregnancy complications like pre-eclampsia, gestational diabetes, etc resolve after childbirth. However, pregnancy complications are known to be associated with an increased risk of new long-term health conditions for women later in life, such as cardiovascular disease. These umbrella reviews aim to summarise systematic reviews evaluating the association between pregnancy complications and five groups of long-term health conditions: autoimmune conditions, cancers, functional disorders, mental health conditions and metabolic health conditions (diabetes and hypertension).

METHODS AND ANALYSIS

We will conduct searches in Medline, Embase and the Cochrane database of systematic reviews without any language restrictions. We will include systematic reviews with or without meta-analyses that studied the association between pregnancy complications and the future risk of the five groups of long-term health conditions in women. Pregnancy complications were identified from existing core outcome sets for pregnancy and after consultation with experts. Two reviewers will independently screen the articles. Data will be synthesised with both narrative and quantitative methods. Where a meta-analysis has been carried out, we will report the combined effect size from individual studies. For binary data, pooled ORs with 95% CIs will be presented. For continuous data, we will use the mean difference with 95% CIs. The findings will be presented in forest plots to assess heterogeneity. The methodological quality of the studies will be evaluated with the AMSTAR 2 tool or the Cochrane risk of bias tool. The corrected covered area method will be used to assess the impact of overlap in reviews. The findings will be used to inform the design of prediction models, which will predict the risk of women developing these five group of health conditions following a pregnancy complication.

ETHICS AND DISSEMINATION

No ethical approvals required. Findings will be disseminated through publications in peer-reviewed journals and conference presentations.

How well do polygenic risk scores identify men at high risk for prostate cancer? Systematic review and meta-analysis

OBJECTIVES

Genome-wide association studies have revealed over 200 genetic susceptibility loci for prostate cancer (PCa). By combining them, polygenic risk scores (PRS) can be generated to predict risk of PCa. We summarize the published evidence and conduct meta-analyses of PRS as a predictor of PCa risk in Caucasian men.

PATIENTS AND METHODS

Data were extracted from 59 studies, with 16 studies including 17 separate analyses used in the main meta-analysis with a total of 20,786 cases and 69,106 controls identified through a systematic search of ten databases. Random effects meta-analysis was used to obtain pooled estimates of area under the receiver-operating characteristic curve (AUC). Meta-regression was used to assess the impact of number of single-nucleotide polymorphisms (SNPs) incorporated in PRS on AUC. Heterogeneity is expressed as I² scores. Publication bias was evaluated using funnel plots and Egger tests.

RESULTS

The ability of PRS to identify men with PCa was modest (pooled AUC 0.63, 95% CI 0.62-0.64) with moderate consistency (I² 64%). Combining PRS with clinical variables increased the pooled AUC to 0.74 (0.68-0.81). Meta-regression showed only negligible increase in AUC for adding incremental SNPs. Despite moderate heterogeneity, publication bias was not evident.

CONCLUSION

Typically, PRS accuracy is comparable to PSA or family history with a pooled AUC value 0.63 indicating mediocre performance for PRS alone.

Reduction in shock burden with catheter ablation versus escalated antiarrhythmic drug therapy: Insights from the VANISH trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1. Canadian Institutes of Health Research (CIHR)

2. Additional financial support from St. Jude Medical and Biosense Webster

Background

Recurrent shocks for ventricular tachycardia (VT) are associated with an increased risk of heart failure and mortality and have a negative influence on quality of life. Catheter ablation has been shown to improve VT event-free survival in patients with antiarrhythmic drug (AAD)-refractory VT and prior myocardial infarction (MI); however, the effects of ablation on shock burden has yet to be investigated.

Purpose

Our primary objectives were to compare the shock-treated VT event burden and appropriate shock burden following randomization to treatment with either catheter ablation or escalated AAD therapy among VT patients with prior MI in the Ventricular tachycardia AblatioN versus escalated antiarrhythmic drug therapy in Ischemic Heart disease (VANISH) randomized trial.

Methods

Recurrent event analyses were performed using the intention-to-treat population of the VANISH trial. Shock-treated VT event burden was defined as the total number of VT events treated with ≥1 appropriate internal or external shocks. Appropriate shock burden was defined as the total number of appropriate internal and external shocks delivered, regardless of the number of VT events. All VT events and implantable cardioverter defibrillator (ICD) therapies were adjudicated by reviewers blinded to the treatment allocation. Three recurrent event models were used to compare the shock burden between treatment arms (Anderson-Gill (AG), Frailty, and Prentice, Williams, and Peterson Total Time (PWP-TT). Each model clustered by patient and accounted for competing risk of death with the Fine and Gray sub-distributions hazards model.

Results

Of the 259 patients enrolled in the VANISH trial [median age 69.8 (IQR 63.0-74.2) years, 7.0% women], 132 patients were randomized to ablation and 129 patients to escalated AAD therapy. Over a median follow-up of 23.4 (IQR 14.7-40.4) months, there were 138 shock-treated VT events [39.07 (95% CI 33.14-46.07) shock-treated VT events per 100 person-years] in the ablation arm and 218 shock-treated VT events [64.60 (95% CI 56.49–73.84) shock-treated VT events per 100 person-years] in the escalated AAD therapy arm (Figure 1). Ablation patients had a 40% lower shock-treated VT event burden (ie. number of shock-treated VT events) compared to patients randomized to escalated AAD therapy [Figure 1; AG HR 0.60 (95% 0.38-0.95)]. Further, there was also a statistically significant reduction in the appropriate shock burden (i.e. number of appropriate shocks) among ablation patients (169 appropriate shocks) compared to escalated AAD therapy patients (266 appropriate shocks) [Figure 1; AG HR 0.61 (95% CI 0.37-0.96)]. All results were consistent between the 3 recurrent event models.

Conclusion

Among patients with AAD-refractory VT and a prior MI, catheter ablation reduced shock-treated VT event burden and appropriate shock burden compared to escalated AAD therapy.

The Key Role of Patient Involvement in the Development of Core Outcome Sets in Prostate Cancer

Patients are the stewards of their own care and hence their voice is important when designing and implementing research. Patients should be involved not only as participants in research that impacts their care, as the recipients of that care and any associated harms, but also as research collaborators in prioritising important questions from the patient perspective and designing the research and the ways in which is it most appropriate to involve patients. The PIONEER Consortium, an international multistakeholder collaboration lead by the European Association of Urology, has developed a core outcome set (COS) for localised and metastatic prostate cancer relevant to all stakeholders in particular patients. Throughout the work of PIONEER, patient representatives were involved as collaborators in setting the research agenda, and a wider group of patients was involved as participants in developing COSs, for instance in consensus meetings on choosing important outcomes and appropriate definitions. This publication showcases the process for COS development and highlights the most important recommendations to ultimately inform future research projects co-created between patients and other stakeholders. PATIENT SUMMARY: An important step in involving patients in the selection of outcomes for clinical trials, clinical audits, and real-world evidence is the development of a core outcome set (COS) that is relevant to all stakeholders. This report highlights the patient participation throughout our PIONEER COS development. TAKE HOME  MESSAGE: An important step in involving patients in the selection of outcomes for clinical trials, clinical audits, and real-world evidence is to develop a core outcome set (COS) that is relevant to all stakeholders. As part of the work of the PIONEER Consortium, we aim to highlight the patient participation throughout our PIONEER COS development.

Perioperative atrial fibrillation and risk of stroke after cardiac surgery: a systematic review and meta-analysis

Background

Perioperative atrial fibrillation (POAF) after cardiac surgery has been associated with an increased risk of stroke. However, many previous studies have not systematically excluded patients with pre-existing AF. As such, the association between new-onset POAF and stroke risk has not been well established.

Purpose

To perform a systematic review and meta-analysis on the short and long-term risks of stroke in patients experiencing new-onset POAF after cardiac surgery.

Methods

We searched MEDLINE, EMBASE, and the Cochrane Library databases for studies comparing the risk of stroke in patients with versus without new-onset POAF after cardiac surgery. Studies were included in our review if they enrolled ≥100 patients and defined POAF as new-onset AF in patients with no history of preoperative AF. Data were independently extracted in duplicate. The quality of studies was assessed using the Newcastle Ottawa Scale. Random-effects meta-analysis was used to calculate summary risk ratios. Short-term stroke risk was calculated using events occurring either in-hospital or ≤30 days after surgery, and long-term risk was calculated using events occurring >30 days after surgery.

Results

After reviewing 11,791 citations, 46 studies met the inclusion criteria. These studies included 364,822 patients, of which 76,388 (20.9%) developed new-onset POAF. The incidence of stroke was higher among patients with POAF versus no POAF (n=44 studies; incidence 2.76% vs. 1.53%; relative risk (RR) 1.91, 95% CI 1.65–2.23; I2 = 78%). A sensitivity analysis of high-quality studies alone yielded similar results (n=9 studies; RR 1.74, 95% CI 1.31–2.30; I2 = 88%). Patients with POAF had a higher incidence of stroke both in the short-term (n=35 studies; 2.71% vs. 1.36%; RR 2.13, 95% CI 1.81–2.51; I2 = 69%) and long-term (n=20 studies; 1.6 vs. 1.0 per 100 patient-years; RR 1.39, 95% CI 1.24–1.57; I2 = 27%). The risk of stroke was increased in POAF patients across all types of cardiac surgery performed, including isolated CABG (n=19 studies; RR 1.93, 95% CI 1.60–2.32; I2 = 62%), isolated transcatheter aortic valve implantation (n=7 studies; RR 1.86, 95% CI 1.32–2.63; I2 = 0%), and studies including multiple procedure types (n=16 studies; RR 1.90, 95% CI 1.44–2.51; I2 = 89%).

Conclusion

New-onset POAF after cardiac surgery is associated with an increased risk of stroke, both in the short and long term. The absolute risk difference is small, and randomized trials are needed to assess the efficacy and safety of treatment interventions in this patient population.

Funding Acknowledgement

Type of funding source: None

Vitamin K antagonists versus direct oral anticoagulants after cardiac surgery: a 31-country cohort study

Background

About 10% of patients undergoing cardiac surgery have a history of atrial fibrillation (AF). Among these patients, uncertainty exists regarding the safest and most effective oral anticoagulant (OAC) during the postoperative period.

Purpose

To evaluate practice patterns regarding OAC early after cardiac surgery in patients with a preoperative history of AF and to compare the safety and effectiveness of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs).

Methods

We conducted a nested cohort study within the Left Atrial Appendage Occlusion Study (LAAOS) III (NCT01561651). LAAOS III included patients with AF undergoing cardiac surgery with a CHA2DS2-VASC ≥2. In this substudy, we examined patients without end-stage renal dysfunction (eGFR >30 mL/min/1.73m2) who were discharged on OAC. We evaluated bleeding and thromboembolism within 90 days postoperatively using logistic regression adjusting for CHA2DS2-VASC score.

Results

Recruitment started in 2012 and completed in 2018 in 113 centres in 31 countries. Of the 4811 patients enrolled in LAAOS III, 3725 (77%) were included in this substudy. Preoperatively, 58% of patients received OAC: 56% DOACs and 44% VKAs. At hospital discharge 23% received DOACs and 77% VKAs; 55% of patients on a DOAC at baseline were switched to a VKA while 5% of patients on a VKA were switched to a DOAC. Patients discharged on a DOAC were older, had a higher CHA2DS2-VASC, and were more likely to be male. Patients having undergone an isolated coronary bypass procedure were more likely prescribed DOACs than VKAs (41% vs 23%, p<0.001) whereas isolated non-mechanical valve patients were more likely to be prescribed VKAs (43% vs 28%, p<0.001). Switching from a DOAC to a VKA postoperatively occurred in 42% of patients In Australia/New Zealand, 49% in Europe, and 63% in North America. Major bleeding between 48 hours postoperatively and 30 days occurred in 1.5% in the DOAC group and 1.3% in the VKA group (aOR 1.14, 95% CI 0.60–2.15, p=0.69) while between 48 hours and 90 days, it occurred in 1.8% of patients in both groups (aOR 0.97, 95% CI, 0.54–1.17, p=0.91). Cardiac tamponade, the composite of stroke and systemic arterial embolism, and the composite of stroke, systemic arterial embolism and death did not differ significantly at 30 and 90 days between the DOAC and VKA groups.

Conclusions

VKAs was the dominant OAC used early after cardiac surgery, but postoperative OAC practices varied by region. After adjustment for CHA2DS2-VASC score, the early postoperative incidence of major bleeding and of the composite of stroke and systemic arterial embolism did not differ significantly when DOACs were compared with VKAs.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): CIHR, Heart and Stroke Foundation

Surgical Outcome and Oncological Survival of Osteofibrous Dysplasia-Like and Classic Adamantinomas: An International Multicenter Study of 318 Cases

BACKGROUND

Osteofibrous dysplasia-like adamantinoma (OFD-AD) and classic adamantinoma (AD) are rare, neoplastic diseases with only limited data supporting current treatment protocols. We believe that our retrospective multicenter cohort study is the largest analysis of patients with adamantinoma to date. The primary purpose of this study was to describe the disease characteristics and evaluate the oncological outcomes. The secondary purpose was to identify risk factors for local recurrence after surgical treatment and propose treatment guidelines.

METHODS

Three hundred and eighteen confirmed cases of OFD-AD and AD for which primary treatment was carried out between 1985 and 2015 were submitted by 22 tertiary bone tumor centers. Proposed clinical risk factors for local recurrence such as size, type, and margins were analyzed using univariable and multivariate Cox regression analysis.

RESULTS

Of the 318 cases, 128 were OFD-AD and 190 were AD. The mean age at diagnosis was 17 years (median, 14.5 years) for OFD-AD and 32 years (median, 28 years) for AD; 53% of the patients were female. The mean tumor size in the OFD-AD and AD groups combined was 7.8 cm, measured histologically. Sixteen percent of the patients sustained a pathological fracture prior to treatment. Local recurrence was recorded in 22% of the OFD-AD cases and 24% of the AD cases. None of the recurrences in the OFD-AD group progressed to AD. Metastatic disease was found in 18% of the AD cases and fatal disease, in 11% of the AD cases. No metastatic or fatal disease was reported in the OFD-AD group. Multivariate Cox regression analysis demonstrated that uncontaminated resection margins (hazard ratio [HR] = 0.164, 95% confidence interval [CI] = 0.092 to 0.290, p < 0.001), pathological fracture (HR = 1.968, 95% CI = 1.076 to 3.600, p = 0.028), and sex (female versus male: HR = 0.535, 95% CI = 0.300 to 0.952, p = 0.033) impacted the risk of local recurrence.

CONCLUSIONS

OFD-AD and AD are parts of a disease spectrum but should be regarded as different entities. Our results support reclassification of OFD-AD into the intermediate locally aggressive category, based on the local recurrence rate of 22% and absence of metastases. In our study, metastatic disease was restricted to the AD group (an 18% rate). We advocate wide resection with uncontaminated margins including bone and involved periosteum for both OFD-AD and AD.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgery for women with endometrioma prior to in vitro fertilisation: proposal for a feasible multicentre randomised clinical trial in the UK

STUDY QUESTION

Is it feasible to undertake a randomised controlled trial to establish whether surgical removal of endometrioma or not, improves live birth rates from IVF?

SUMMARY ANSWER

A randomised controlled trial (RCT) comparing surgery versus no surgery to endometrioma prior to IVF is only feasible in UK if an adaptive rather than traditional study design is used; this would minimise resource wastage and complete the trial in an acceptable time frame.

WHAT IS KNOWN ALREADY

There is wide variation in the management of endometriomas prior to IVF, with decisions about treatment being influenced by personal preferences.

STUDY DESIGN, SIZE, AND DURATION

This was a mixed-methods study consisting of an online survey of clinicians, a focus group and individual interviews with potential trial participants.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Endometriosis and fertility experts across the UK were invited to participate in an online anonymised questionnaire. Potential future trial participants were recruited from a tertiary care fertility centre and invited to participate in either individual interviews or focus groups.

MAIN RESULTS AND THE ROLE OF CHANCE

Clinicians and potential trial participants confirmed the need for an RCT to inform the management of an endometrioma prior to IVF. There were 126 clinicians who completed the survey, and the majority (70%) were willing to recruit to a trial. Half of those who responded indicated that they see at least 10 eligible women each year. The main barriers to recruitment were waiting lists for surgery and access to public funding for IVF. One focus group (n = 7) and five interviews were conducted with potential trial participants (n = 3) and their partners (n = 2). The findings from these discussions highlighted that recruitment and retention in a potential RCT could be improved by coordination between IVF and surgical services such that an operation does not delay IVF or affect access to public funding. Live birth was considered the most important outcome with an improvement of at least 10% considered the minimum acceptable by both patients and clinicians.

LIMITATIONS, REASONS FOR CAUTION

This feasibility study captured views of clinicians across the UK, but as patients were from a single Scottish centre, their views may not be representative of other areas with limited public funding for IVF.

WIDER IMPLICATIONS OF THE FINDINGS

There is a need for an appropriately powered RCT to establish whether or not surgical treatment of endometrioma prior to IVF improves live birth rates. There are logistical issues to be considered due to limited number of participants, funding of IVF and waiting times. These could be overcome in a RCT by using an adaptive design which would include a prospectively planned opportunity for modification of specified aspects of the study design based on interim analysis of the data, coordination of IVF treatments and endometriosis surgeries and international collaboration. Similar principles could be used for other questions in fertility where a traditional approach for randomised trials is not feasible.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was received from the NHS Grampian R&D pump priming fund (RG14437-12). S.B. is Editor-in-Chief of HROPEN, and A.W.H. is Deputy Editor of HROPEN. Neither was involved in the review of this manuscript. L.S. reports grants from CSO and NIHR to do endometriosis research, outside the submitted work. K.C. reports grants from NIHR/HTA and CSO during the conduct of the study. J.H.e., A.W.H., J.D., S.B.r., K.B., G.B., J.H.u. and K.G. report no conflict of interest.

Multi-centre variability of ISCEV standard ERGs in two normal adults

BACKGROUND

The reproducibility of an individual's full-field ERG between centres has not previously been investigated.

METHODS

ERGs were recorded using both silver thread and skin electrodes from the same two normal adult subjects at 15 UK centres using routine, local protocols and a highly standardised, 'ISCEV-specified' protocol matching the values specified in the ISCEV standard; where the ISCEV standard allows options, a single value was chosen.

RESULTS

Inter-ocular differences were small, and amplitudes were smaller for skin than silver thread electrodes. No centre produced outlying data points, and ERGs across all 15 centres were remarkably similar. Amplitude variability was less for local protocols (using LED flashes) than for the ISCEV-specified protocol using xenon flashes (22 vs. 24 %, p = 0.01), but peak time variability was less for the ISCEV-specified protocol (6.1 vs. 7.4 %, p = 0.001). Only the DA 0.01 ERG correlated with photometric variability. The bifidity of the DA 3 a-wave doubled its peak time variability compared with the DA 10 a-wave.

CONCLUSIONS

Inter-centre amplitude variability was typically within clinically significant thresholds, suggesting that inter-centre variability with suitable standardisation may not add more to total variability than inter-subject variability. Variability improvements gained by the tighter specifications of the ISCEV-specified protocol were possibly more than lost due to imprecisions of xenon flashtubes. Peak time variability was far lower than amplitude variability, corresponding with acceptable variability of biochemical assays. These results represent a vindication of the existence of an ERG standard and suggest that further standardisation would lend itself to greater reproducibility of ERGs worldwide.