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Leston M, Elson W, Ordóñez-Mena JM, Kar D, Whitaker H, Joy M, Roberts N, Hobbs FDR, de Lusignan S. Disparities in COVID-19 mortality amongst the immunosuppressed: A systematic review and meta-analysis for enhanced disease surveillance. J Infect 2024; 88:106110. [PMID: 38302061 PMCID: PMC10943183 DOI: 10.1016/j.jinf.2024.01.009] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Effective disease surveillance, including that for COVID-19, is compromised without a standardised method for categorising the immunosuppressed as a clinical risk group. METHODS We conducted a systematic review and meta-analysis to evaluate whether excess COVID-associated mortality compared to the immunocompetent could meaningfully subdivide the immunosuppressed. Our study adhered to UK Immunisation against infectious disease (Green Book) criteria for defining and categorising immunosuppression. Using OVID (EMBASE, MEDLINE, Transplant Library, and Global Health), PubMed, and Google Scholar, we examined relevant literature between the entirety of 2020 and 2022. We selected for cohort studies that provided mortality data for immunosuppressed subgroups and immunocompetent comparators. Meta-analyses, grey literature and any original works that failed to provide comparator data or reported all-cause or paediatric outcomes were excluded. Odds Ratios (OR) and 95% confidence intervals (CI) of COVID-19 mortality were meta-analysed by immunosuppressed category and subcategory. Subgroup analyses differentiated estimates by effect measure, country income, study setting, level of adjustment, use of matching and publication year. Study screening, extraction and bias assessment were performed blinded and independently by two researchers; conflicts were resolved with the oversight of a third researcher. PROSPERO registration number is CRD42022360755. FINDINGS We identified 99 unique studies, incorporating data from 1,542,097 and 56,248,181 unique immunosuppressed and immunocompetent patients with COVID-19 infection, respectively. Compared to immunocompetent people (pooled OR, 95%CI), solid organ transplants (2.12, 1.50-2.99) and malignancy (2.02, 1.69-2.42) patients had a very high risk of COVID-19 mortality. Patients with rheumatological conditions (1.28, 1.13-1.45) and HIV (1.20, 1.05-1.36) had just slightly higher risks than the immunocompetent baseline. Case type, setting income and mortality data matching and adjustment were significant modifiers of excess immunosuppressed mortality for some immunosuppressed subgroups. INTERPRETATION Excess COVID-associated mortality among the immunosuppressed compared to the immunocompetent was seen to vary significantly across subgroups. This novel means of subdivision has prospective benefit for targeting patient triage, shielding and vaccination policies during periods of high disease transmission.
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Affiliation(s)
- Meredith Leston
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom.
| | - Willam Elson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Jose M Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Debasish Kar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Heather Whitaker
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, United Kingdom
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Old Campus Road, Old Campus Research Building, Headington, Oxford OX3 7DQ, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
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Fawkner-Corbett D, Hayward G, Alkhmees M, Van Den Bruel A, Ordóñez-Mena JM, Holtman GA. Diagnostic accuracy of blood tests of inflammation in paediatric appendicitis: a systematic review and meta-analysis. BMJ Open 2022; 12:e056854. [PMID: 36328382 PMCID: PMC9639107 DOI: 10.1136/bmjopen-2021-056854] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Possible childhood appendicitis is a common emergency presentation. The exact value of blood tests is debated. This study sought to determine the diagnostic accuracy of four blood tests (white cell count (WCC), neutrophil(count or percentage), C reactive protein (CRP) and/or procalcitonin) for childhood appendicitis. DESIGN A systematic review and diagnostic meta-analysis. Data sources included MEDLINE, EMBASE, Central, Web of Science searched from inception-March 2022 with reference searching and authors contacted for missing/unclear data. Eligibility criteria was studies reporting the diagnostic accuracy of the four blood tests compared to the reference standard (histology or follow-up). Risk of bias was assessed (QUADAS-2), pooled sensitivity and specificity were generated for each test and commonly presented cut-offs. To provide insight into clinical impact, we present strategies using a hypothetical cohort. RESULTS 67 studies were included (34 839 children, 13 342 with appendicitis), all in the hospital setting. The most sensitive tests were WCC (≥10 000 cells/µL, 53 studies sensitivity 0.85 (95% CI 0.80 to 0.89)) and absolute neutrophil count (ANC) (≥7500 cells/µL, five studies sensitivity 0.90 (95% CI 0.85 to 0.94)). Combination of WCC or CRP increased sensitivity further(≥10 000 cells/µL or ≥10 mg/L, individual patient data (IPD) of 6 studies, 0.97 (95% CI 0.93 to 0.99)).Applying results to a hypothetical cohort(1000 children with appendicitis symptoms, of whom 400 have appendicitis) 60 and 40 children would be wrongly discharged based solely on WCC and ANC, respectively, 12 with combination of WCC or CRP.The most specific tests were CRP alone (≥50 mg/L, 38 studies, specificity 0.87 (95% CI 0.80 to 0.91)) or combined with WCC (≥10 000 cells/µL and ≥50 mg/L, IPD of six studies, 0.93 (95% CI 0.91 to 0.95)). CONCLUSIONS The best performing single blood tests for ruling-out paediatric appendicitis are WCC or ANC; with accuracy improved combining WCC and CRP. These tests could be used at the point of care in combination with clinical prediction rules. We provide insight into the best cut-offs for clinical application. PROSPERO REGISTRATION NUMBER CRD42017080036.
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Affiliation(s)
- David Fawkner-Corbett
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Academic Paediatric Surgery Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, UK
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DS, UK
| | - Gail Hayward
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Mohammed Alkhmees
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ann Van Den Bruel
- EPI-Centre, Academic Centre for Primary Care, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
| | - Jose M Ordóñez-Mena
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Gea A Holtman
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Ordóñez-Mena JM, Fanshawe TR, Foster D, Andersson M, Oakley S, Stoesser N, Walker AS, Hayward G. Frequencies and patterns of microbiology test requests from primary care in Oxfordshire, UK, 2008-2018: a retrospective cohort study of electronic health records to inform point-of-care testing. BMJ Open 2021; 11:e048527. [PMID: 34815274 PMCID: PMC8611454 DOI: 10.1136/bmjopen-2020-048527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To inform point-of-care test (POCT) development, we quantified the primary care demand for laboratory microbiology tests by describing their frequencies overall, frequencies of positives, most common organisms identified, temporal trends in testing and patterns of cotesting on the same and subsequent dates. DESIGN Retrospective cohort study. SETTING Primary care practices in Oxfordshire. PARTICIPANTS 393 905 patients (65% female; 49% aged 18-49). PRIMARY AND SECONDARY OUTCOME MEASURES The frequencies of all microbiology tests requested between 2008 and 2018 were quantified. Patterns of cotesting were investigated with heat maps. All analyses were done overall, by sex and age categories. RESULTS 1 596 752 microbiology tests were requested. Urine culture±microscopy was the most common of all tests (n=673 612, 42%), was mainly requested without other tests and was the most common test requested in follow-up within 7 and 14 days. Of all urine cultures, 180 047 (27%) were positive and 172 651 (26%) showed mixed growth, and Escherichia coli was the most prevalent organism (132 277, 73% of positive urine cultures). Antenatal urine cultures and blood tests in pregnancy (hepatitis B, HIV and syphilis) formed a common test combination, consistent with their use in antenatal screening. CONCLUSIONS The greatest burden of microbiology testing in primary care is attributable to urine culture ± microscopy; genital and routine antenatal urine and blood testing are also significant contributors. Further research should focus on the feasibility and impact of POCTs for these specimen types.
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Affiliation(s)
- J M Ordóñez-Mena
- Department of Primary Care Health Sciences, University of Oxford Nuffield, Oxford, Oxfordshire, UK
- NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Thomas R Fanshawe
- Department of Primary Care Health Sciences, University of Oxford Nuffield, Oxford, Oxfordshire, UK
| | - Dona Foster
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Monique Andersson
- Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Sarah Oakley
- Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Nicole Stoesser
- NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
- Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - A Sarah Walker
- NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Gail Hayward
- Department of Primary Care Health Sciences, University of Oxford Nuffield, Oxford, Oxfordshire, UK
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Ordóñez-Mena JM, Walter V, Schöttker B, Jenab M, O'Doherty MG, Kee F, Bueno-de-Mesquita B, Peeters PHM, Stricker BH, Ruiter R, Hofman A, Söderberg S, Jousilahti P, Kuulasmaa K, Freedman ND, Wilsgaard T, Wolk A, Nilsson LM, Tjønneland A, Quirós JR, van Duijnhoven FJB, Siersema PD, Boffetta P, Trichopoulou A, Brenner H. Impact of prediagnostic smoking and smoking cessation on colorectal cancer prognosis: a meta-analysis of individual patient data from cohorts within the CHANCES consortium. Ann Oncol 2018; 29:472-483. [PMID: 29244072 PMCID: PMC6075220 DOI: 10.1093/annonc/mdx761] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Smoking has been associated with colorectal cancer (CRC) incidence and mortality in previous studies and might also be associated with prognosis after CRC diagnosis. However, current evidence on smoking in association with CRC prognosis is limited. Patients and methods For this individual patient data meta-analysis, sociodemographic and smoking behavior information of 12 414 incident CRC patients (median age at diagnosis: 64.3 years), recruited within 14 prospective cohort studies among previously cancer-free adults, was collected at baseline and harmonized across studies. Vital status and causes of death were collected for a mean follow-up time of 5.1 years following cancer diagnosis. Associations of smoking behavior with overall and CRC-specific survival were evaluated using Cox regression and standard meta-analysis methodology. Results A total of 5229 participants died, 3194 from CRC. Cox regression revealed significant associations between former [hazard ratio (HR) = 1.12; 95 % confidence interval (CI) = 1.04-1.20] and current smoking (HR = 1.29; 95% CI = 1.04-1.60) and poorer overall survival compared with never smoking. Compared with current smoking, smoking cessation was associated with improved overall (HR<10 years = 0.78; 95% CI = 0.69-0.88; HR≥10 years = 0.78; 95% CI = 0.63-0.97) and CRC-specific survival (HR≥10 years = 0.76; 95% CI = 0.67-0.85). Conclusion In this large meta-analysis including primary data of incident CRC patients from 14 prospective cohort studies on the association between smoking and CRC prognosis, former and current smoking were associated with poorer CRC prognosis compared with never smoking. Smoking cessation was associated with improved survival when compared with current smokers. Future studies should further quantify the benefits of nonsmoking, both for cancer prevention and for improving survival among CRC patients, in particular also in terms of treatment response.
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Affiliation(s)
- J M Ordóñez-Mena
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany; Network Aging Research, University of Heidelberg, Heidelberg, Germany; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - V Walter
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - B Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany; Network Aging Research, University of Heidelberg, Heidelberg, Germany; Institute of Health Care and Social Sciences, FOM University, Essen, Germany
| | - M Jenab
- International Agency for Research on Cancer (IARC), Lyon, France
| | - M G O'Doherty
- UKCRC Centre of Excellence for Public Health, Queens University of Belfast, Belfast, UK
| | - F Kee
- UKCRC Centre of Excellence for Public Health, Queens University of Belfast, Belfast, UK
| | - B Bueno-de-Mesquita
- Department of Chronic Diseases, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands; Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, The Netherlands; Division of Epidemiology and Biostatistics, The School of Public Health, Imperial College London, London, UK; Department of Social & Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - P H M Peeters
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B H Stricker
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - R Ruiter
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - A Hofman
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - S Söderberg
- Department of Public Health and Clinical Medicine, Cardiology, and Heart Center, Umeå University, Umeå, Sweden
| | - P Jousilahti
- National Institute for Health and Welfare (THL), Helsinki, Finland
| | - K Kuulasmaa
- National Institute for Health and Welfare (THL), Helsinki, Finland
| | - N D Freedman
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, USA
| | - T Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - A Wolk
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - L M Nilsson
- Nutritional Research, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; Arcum, Arctic Research Centre at Umeå University, Umeå, Sweden
| | - A Tjønneland
- Diet, Genes and Environment, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - J R Quirós
- Public Health Directorate, Asturias, Spain
| | | | - P D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P Boffetta
- Hellenic Health Foundation, Athens, Greece; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - A Trichopoulou
- Hellenic Health Foundation, Athens, Greece; WHO Collaborating Center for Nutrition and Health, Unit of Nutritional Epidemiology and Nutrition in Public Health, Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece
| | - H Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany; Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany; German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
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